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Batterton KA, Schubert CM, Warr RL. A fiducial-based confidence interval for the linear combination of multinomial probabilities. Biom J 2023; 65:e2300065. [PMID: 37694601 DOI: 10.1002/bimj.202300065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Revised: 06/25/2023] [Accepted: 07/17/2023] [Indexed: 09/12/2023]
Abstract
Across a broad set of applications, system outcomes may be summarized as probabilities in confusion or contingency tables. In settings with more than two outcomes (e.g., stages of cancer), these outcomes represent multinomial experiments. Measures to summarize system performance have been presented as linear combinations of the resulting multinomial probabilities. Statistical inference on the linear combination of multinomial probabilities has been focused on large-sample and parametric settings and not small-sample settings. Such inference is valuable, however, especially in settings such as those resulting from pilot or low-cost studies. To address this gap, we leverage the fiducial approach to derive confidence intervals around the linear combination of multinomial parameters with desirable frequentist properties. One of the original arguments against the fiducial approach was its inability to extend to multiparameter settings. Therefore, the great novelty of this work is both the derived interval and the logical framework for applying the fiducial approach in multiparameter settings. Through simulation, we demonstrate that the proposed method maintains a minimum coverage of1 - α $1 - \alpha$ , unlike the bootstrap and large-sample methods, at comparable interval lengths. Finally, we illustrate its use in a medical problem of selecting classifiers for diagnosing chronic allograph nephropathy in postkidney transplant patients.
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Affiliation(s)
- Katherine A Batterton
- Department of Mathematics and Statistics, Air Force Institute of Technology, Ohio, USA
| | - Christine M Schubert
- Department of Mathematics and Statistics, Air Force Institute of Technology, Ohio, USA
| | - Richard L Warr
- Department of Statistics, Brigham Young University, Provo, Utah, USA
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Grap MJ, Schubert CM, Munro CL, Wetzel PA, Burk RS, Lucas V, Pepperl A. OR Time and Sacral Pressure Injuries in Critically Ill Surgical Patients. AORN J 2020; 109:229-239. [PMID: 30694547 DOI: 10.1002/aorn.12583] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Critically ill patients are at risk for developing pressure injuries during operative and other invasive procedures. The purpose of this secondary analysis was to explore the relationship of OR time to sacral pressure injuries in critically ill patients using high frequency ultrasound as a method of assessment. The 41 participants examined in this study had both time in the OR and up to eight days of pressure injury data. The multivariable model containing OR bed time, body mass index, and Braden Scale score produced the best prediction of pressure injury (area under the curve = 0.859). A higher body mass index (P = .09), shorter OR bed time (P = .01), and lower Braden Scale score (P = .05) were associated with a greater chance of pressure injury. These results suggest that use of high frequency ultrasound may identify tissue changes before observable skin changes, leading to earlier pressure injury prevention strategies.
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Grap MJ, Schubert CM, Burk RS. Author Response: Sacral Pressure Injury Study Commentary. AORN J 2019; 110:358. [DOI: 10.1002/aorn.12826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Mary Jo Grap
- Virginia Commonwealth University School of Nursing Richmond VA
| | | | - Ruth S. Burk
- Georgia Baptist College of Nursing of Mercer University Atlanta GA
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McClish DK, Wilk AR, Schubert CM. Choosing between the BP and BN sequential strategies. Pharm Stat 2019; 18:533-545. [PMID: 31069929 DOI: 10.1002/pst.1945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Revised: 01/16/2019] [Accepted: 03/05/2019] [Indexed: 11/06/2022]
Abstract
Cost and burden of diagnostic testing may be reduced if fewer tests can be applied. Sequential testing involves selecting a sequence of tests, but only administering subsequent tests dependent on results of previous tests. This research provides guidance to choosing between single tests or the believe the positive (BP) and believe the negative (BN) sequential testing strategies, using accuracy (as measured by the Youden Index) as the primary determinant. Approximately 75% of the parameter combinations examined resulted in either BP or BN being recommended based on a higher accuracy at the optimal point. In about half of the scenarios BP was preferred, and the other half, BN, with the choice often a function of the value of the ratio of standard deviations of those without and with disease (b). Large values of b for the first test of the sequence tended to be associated with preference for BN as opposed to BP, while small values of b appear to favor BP. When there was no preference between sequences and/or single tests based on the Youden Index, cost of the sequence was considered. In this case, disease prevalence plays a large role in the selection of strategies, with lower values favoring BN and sometimes higher values favoring BP. The cost threshold for the sequential strategy to be preferred over a single, more accurate test, was often quite high. It appears that while sequential strategies most often increase diagnostic accuracy over a single test, sequential strategies are not always preferred.
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Affiliation(s)
- Donna K McClish
- Department of Biostatistics, Virginia Commonwealth University, Richmond, Virginia
| | - Amber R Wilk
- Department of Biostatistics, Virginia Commonwealth University, Richmond, Virginia.,United Network for Organ Sharing, Richmond, Virginia
| | - Christine M Schubert
- Department of Mathematics and Statistics, Air Force Institute of Technology, Wright-Patterson Air Force Base, Ohio
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Barker SB, Schubert CM, Barker RT, Kuo SIC, Kendler KS, Dick DM. The Relationship between Pet Ownership, Social Support, and Internalizing Symptoms in Students from the First to Fourth Year of College. Appl Dev Sci 2018; 24:279-293. [PMID: 32742161 PMCID: PMC7394412 DOI: 10.1080/10888691.2018.1476148] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Internalizing symptoms are prevalent in students as they enter and complete college. Considering research suggesting mental health benefits of pet ownership, this study explores the relationship between pet ownership, social support (SS), and internalizing symptoms (IS) in a cohort of students across their 4-year college experience. With no differences at college entry, students growing up with pets had greater IS through the fourth year, and greater SS through the third year, than those without pets. Currently living with a pet, gender, SS and personality predicted IS in the fourth year. Females experiencing higher IS in their first year are more likely to live with pets in their fourth year, and fourth year females living with pets or greatly missing absent pets have higher IS than females without pets or missing pets less. Findings suggest a unique relationship between IS in female students and their pet relationships not seen in males.
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Affiliation(s)
- Sandra B. Barker
- Department of Psychiatry, Center for Human-Animal Interaction, Virginia Commonwealth University, Richmond, Virginia,
USA
| | - Christine M. Schubert
- Department of Mathematics and Statistics, Air Force Institute of Technology, Wright-Patterson Air Force Base, Ohio,
USA
| | - Randolph T. Barker
- School of Business, Virginia Commonwealth University, Richmond, Virginia, USA
| | | | - Kenneth S. Kendler
- Virginia Institute for Psychiatric and Behavioral Genetics, Department of Psychiatry, Virginia Commonwealth
University
| | - Danielle M. Dick
- Departments of Psychology, African American Studies, and Human and Molecular Genetics, Virginia Commonwealth
University
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Grap MJ, Munro CL, Schubert CM, Wetzel PA, Burk RS, Pepperl A, Lucas V. Lack of Association of High Backrest With Sacral Tissue Changes in Adults Receiving Mechanical Ventilation. Am J Crit Care 2018; 27:104-113. [PMID: 29496766 DOI: 10.4037/ajcc2018419] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Although higher backrest elevation may be a theoretical risk for integrity of sacral tissues, few data support use of high backrest elevation. OBJECTIVE To describe the effect of backrest elevation on the integrity of sacral tissue in critically ill adults receiving mechanical ventilation. METHODS Patients from 3 critical care units (surgical trauma, medical respiratory, and neuroscience) who were expected to have mechanical ventilation for at least 24 hours were intubated and mechanical ventilation was started. Participants were enrolled in the study within 24 hours of intubation. Backrest elevation was continuously measured by using mechanical system- based accelerometers. Integrity of sacral tissue was evaluated by using high-frequency sonography. RESULTS Data for 84 patients who had measurements of both backrest elevation and skin integrity were available for analysis. General linear models indicated no significant difference among the proportions of time spent at less than 20° (P values: .57 the first 24 hours, .17 the first 48 hours, .81 the first 72 hours), 20° to 30° (P values: .25 the first 24 hours, .08 the first 48 hours, .25 the first 72 hours), or greater than 30° (P values: .62 the first 24 hours, .28 the first 48 hours, .68 the first 72 hours) among participants with no injury, no change in injury, improvement in injury, or injury that worsened. CONCLUSIONS Level of backrest elevation is not associated with changes in tissue integrity. Body positioning in critically ill patients receiving mechanical ventilation may not be as important or as effective as once thought.
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Affiliation(s)
- Mary Jo Grap
- Mary Jo Grap is Nursing Alumni Distinguished Professor and Ruth S. Burk is an assistant professor, Adult Health and Nursing Systems Department, School of Nursing, Paul A. Wetzel is an associate professor and Anathea Pepperl is an assistant professor, Biomedical Engineering Department, School of Engineering, Virginia Commonwealth University, Richmond, Virginia. Valentina Lucas is a nurse practitioner, Department of Surgery, Virginia Commonwealth University Health System, Richmond, Virginia. Cindy L. Munro is dean and professor, School of Nursing and Health Studies, University of Miami, Coral Gables, Florida. Christine M. Schubert is an associate professor, Department of Mathematics and Statistics, Air Force Institute of Technology, Wright-Patterson Air Force Base, Dayton, Ohio.
| | - Cindy L Munro
- Mary Jo Grap is Nursing Alumni Distinguished Professor and Ruth S. Burk is an assistant professor, Adult Health and Nursing Systems Department, School of Nursing, Paul A. Wetzel is an associate professor and Anathea Pepperl is an assistant professor, Biomedical Engineering Department, School of Engineering, Virginia Commonwealth University, Richmond, Virginia. Valentina Lucas is a nurse practitioner, Department of Surgery, Virginia Commonwealth University Health System, Richmond, Virginia. Cindy L. Munro is dean and professor, School of Nursing and Health Studies, University of Miami, Coral Gables, Florida. Christine M. Schubert is an associate professor, Department of Mathematics and Statistics, Air Force Institute of Technology, Wright-Patterson Air Force Base, Dayton, Ohio
| | - Christine M Schubert
- Mary Jo Grap is Nursing Alumni Distinguished Professor and Ruth S. Burk is an assistant professor, Adult Health and Nursing Systems Department, School of Nursing, Paul A. Wetzel is an associate professor and Anathea Pepperl is an assistant professor, Biomedical Engineering Department, School of Engineering, Virginia Commonwealth University, Richmond, Virginia. Valentina Lucas is a nurse practitioner, Department of Surgery, Virginia Commonwealth University Health System, Richmond, Virginia. Cindy L. Munro is dean and professor, School of Nursing and Health Studies, University of Miami, Coral Gables, Florida. Christine M. Schubert is an associate professor, Department of Mathematics and Statistics, Air Force Institute of Technology, Wright-Patterson Air Force Base, Dayton, Ohio
| | - Paul A Wetzel
- Mary Jo Grap is Nursing Alumni Distinguished Professor and Ruth S. Burk is an assistant professor, Adult Health and Nursing Systems Department, School of Nursing, Paul A. Wetzel is an associate professor and Anathea Pepperl is an assistant professor, Biomedical Engineering Department, School of Engineering, Virginia Commonwealth University, Richmond, Virginia. Valentina Lucas is a nurse practitioner, Department of Surgery, Virginia Commonwealth University Health System, Richmond, Virginia. Cindy L. Munro is dean and professor, School of Nursing and Health Studies, University of Miami, Coral Gables, Florida. Christine M. Schubert is an associate professor, Department of Mathematics and Statistics, Air Force Institute of Technology, Wright-Patterson Air Force Base, Dayton, Ohio
| | - Ruth S Burk
- Mary Jo Grap is Nursing Alumni Distinguished Professor and Ruth S. Burk is an assistant professor, Adult Health and Nursing Systems Department, School of Nursing, Paul A. Wetzel is an associate professor and Anathea Pepperl is an assistant professor, Biomedical Engineering Department, School of Engineering, Virginia Commonwealth University, Richmond, Virginia. Valentina Lucas is a nurse practitioner, Department of Surgery, Virginia Commonwealth University Health System, Richmond, Virginia. Cindy L. Munro is dean and professor, School of Nursing and Health Studies, University of Miami, Coral Gables, Florida. Christine M. Schubert is an associate professor, Department of Mathematics and Statistics, Air Force Institute of Technology, Wright-Patterson Air Force Base, Dayton, Ohio
| | - Anathea Pepperl
- Mary Jo Grap is Nursing Alumni Distinguished Professor and Ruth S. Burk is an assistant professor, Adult Health and Nursing Systems Department, School of Nursing, Paul A. Wetzel is an associate professor and Anathea Pepperl is an assistant professor, Biomedical Engineering Department, School of Engineering, Virginia Commonwealth University, Richmond, Virginia. Valentina Lucas is a nurse practitioner, Department of Surgery, Virginia Commonwealth University Health System, Richmond, Virginia. Cindy L. Munro is dean and professor, School of Nursing and Health Studies, University of Miami, Coral Gables, Florida. Christine M. Schubert is an associate professor, Department of Mathematics and Statistics, Air Force Institute of Technology, Wright-Patterson Air Force Base, Dayton, Ohio
| | - Valentina Lucas
- Mary Jo Grap is Nursing Alumni Distinguished Professor and Ruth S. Burk is an assistant professor, Adult Health and Nursing Systems Department, School of Nursing, Paul A. Wetzel is an associate professor and Anathea Pepperl is an assistant professor, Biomedical Engineering Department, School of Engineering, Virginia Commonwealth University, Richmond, Virginia. Valentina Lucas is a nurse practitioner, Department of Surgery, Virginia Commonwealth University Health System, Richmond, Virginia. Cindy L. Munro is dean and professor, School of Nursing and Health Studies, University of Miami, Coral Gables, Florida. Christine M. Schubert is an associate professor, Department of Mathematics and Statistics, Air Force Institute of Technology, Wright-Patterson Air Force Base, Dayton, Ohio
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Burk RS, Grap MJ, Lucas V, Munro CL, Wetzel PA, Schubert CM. High-Frequency Ultrasound: Obtaining Optimal Images and the Effect of Image Artifacts on Image Quality. Adv Wound Care (New Rochelle) 2017; 6:383-391. [PMID: 29098114 DOI: 10.1089/wound.2017.0727] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Accepted: 04/10/2017] [Indexed: 11/12/2022] Open
Abstract
Objective: High-frequency ultrasound (HFUS) images are being researched for use in the prevention, detection, and monitoring of pressure injuries in patients at risk. This seminal longitudinal study in mechanically ventilated adults describes image quality, the incidence of image artifacts, and their effect on image quality in critically ill subjects. Approach: Mechanically ventilated subjects from three adult intensive care units were enrolled, and multiple sacral images from each subject were obtained daily. Using a subset of best image per patient per day, artifacts were grouped, and their effect on image quality was statistically evaluated. Results: Of a total of 1761 images collected from 137 subjects, 8% were rated as poor. In the subset, 70% had good quality ratings. Four groups of artifacts were identified as follows: "bubbles," "texture problems," "layer nondifferentiation," and "reduced area for evaluation." Artifacts from at least one group were found in 83% of images. Bubbles were most frequently seen, but artifacts with adverse effect on image quality were "layer nondifferentiation," "texture problems," and "reduced area for evaluation." Innovation: HFUS image evaluation is still in the development phase with respect to tissue injury use. Artifacts are generally omnipresent. Quickly recognizing artifacts that most significantly affect image quality during scanning will result in higher quality images for research and clinical applications. Conclusion: Good quality images were achievable in study units; although frequent artifacts were present in images, in general, they did not interfere with evaluation. Artifacts related to "layer nondifferentiation" was the greatest predictor of poor image quality, prompting operators to immediately rescan the area.
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Affiliation(s)
- Ruth S. Burk
- Department of Adult Health and Nursing Systems School of Nursing, Virginia Commonwealth University, Richmond, Virginia
| | - Mary Jo Grap
- Department of Adult Health and Nursing Systems School of Nursing, Virginia Commonwealth University, Richmond, Virginia
| | - Valentina Lucas
- Department of Surgery, Virginia Commonwealth University Health System, Richmond, Virginia
| | - Cindy L. Munro
- College of Nursing, University of South Florida, Tampa, Florida
| | - Paul A. Wetzel
- Biomedical Engineering Department, School of Engineering, Virginia Commonwealth University, Richmond, Virginia
| | - Christine M. Schubert
- Department of Mathematics and Statistics, Air Force Institute of Technology, Wright-Patterson Air Force Base, Dayton, Ohio
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Barker SB, Barker RT, Schubert CM. Therapy Dogs on Campus: A Counseling Outreach Activity for College Students Preparing for Final Exams. Journal of College Counseling 2017. [DOI: 10.1002/jocc.12075] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
| | - Randolph T. Barker
- Department of Management; Virginia Commonwealth University
- Now at the School of Medicine Center for Human-Animal Interaction; Virginia Commonwealth University
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Grap MJ, Schubert CM, Burk RS, Lucas V, Wetzel PA, Pepperl A, Munro CL. High frequency ultrasound sacral images in the critically ill: Tissue characteristics versus visual evaluation. Intensive Crit Care Nurs 2017; 42:62-67. [PMID: 28274684 PMCID: PMC5585020 DOI: 10.1016/j.iccn.2017.02.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Revised: 01/29/2017] [Accepted: 02/02/2017] [Indexed: 11/28/2022]
Abstract
PURPOSE High frequency ultrasound (HFUS) systems may identify tissue injury. We compared HFUS tissue characteristics (dermal thickness and dermal density) with visual image examination. METHODS Longitudinal study in critically ill mechanically ventilated adults, from three ICUs (Surgical Trauma, Medical Respiratory, Neuroscience) enrolled within 24hours of airway intubation. Sacral HFUS images were obtained daily for up to seven days. Expert evaluation of the best image per day was completed and compared to HFUS generated tissue characteristics (dermal thickness and dermal density). RESULTS Of the113 subjects with 1614 comparisons analysed, 73.2% to 84% were normal, and 6.3% to 11.8% of the comparisons had injury present but no change was noted in the injury observed. There were no significant differences in one-day comparisons among type of injury and mean dermal thickness (p=0.6645) or dermal median intensity (adjusted p=0.06-0.17). All other day-to-day comparisons were similarly non-significant. CONCLUSIONS We found no association among dermal density, dermal thickness and visual examination of changes in sacral HFUS images for any day-to-day comparison. The use of sacral HFUS as a screening tool for the development of tissue injury is in its infancy. Additional comparative studies should be conducted to identify its future clinical usefulness.
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Affiliation(s)
- Mary Jo Grap
- Adult Health and Nursing Systems, Department of the School of Nursing, Virginia Commonwealth University, Richmond, VA, United States.
| | - Christine M Schubert
- Department of Mathematics and Statistics, Air Force Institute of Technology, Wright-Patterson Air Force Base, Dayton, OH, United States
| | - Ruth S Burk
- Adult Health and Nursing Systems, Department of the School of Nursing, Virginia Commonwealth University, Richmond, VA, United States
| | - Valentina Lucas
- Department of Surgery, Virginia Commonwealth University Heath System, Richmond, VA, United States
| | - Paul A Wetzel
- Biomedical Engineering Department, School of Engineering, Virginia Commonwealth University, Richmond, VA, United States
| | - Anathea Pepperl
- Biomedical Engineering Department, School of Engineering, Virginia Commonwealth University, Richmond, VA, United States
| | - Cindy L Munro
- University of South Florida, Tampa, FL, United States
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Grap MJ, Munro CL, Wetzel PA, Schubert CM, Pepperl A, Burk RS, Lucas V. Backrest Elevation and Tissue Interface Pressure by Anatomical Location During Mechanical Ventilation. Am J Crit Care 2016; 25:e56-63. [PMID: 27134239 DOI: 10.4037/ajcc2016317] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Backrest elevations less than 30° are recommended to reduce pressure ulcers, but positions greater than 30° are recommended during mechanical ventilation to reduce risk for ventilator-associated pneumonia. Interface pressure may vary with level of backrest elevation and anatomical location (eg, sacrum, heels). OBJECTIVE To describe backrest elevation and anatomical location and intensity of skin pressure across the body in patients receiving mechanical ventilation. METHODS In a longitudinal study, patients from 3 adult intensive care units in a single institution receiving mechanical ventilation were enrolled within 24 hours of intubation from February 2010 through May 2012. Backrest elevation (by inclinometer) and pressure (by a pressure-mapping system) were measured continuously for 72 hours. Mean tissue interface pressure was determined for 7 anatomical areas: left and right scapula, left and right trochanter, sacrum, and left and right heel. RESULTS Data on 133 patients were analyzed. For each 1° increase in backrest elevation, mean interface pressure decreased 0.09 to 0.42 mm Hg. For each unit increase in body mass index, mean trochanter pressure increased 0.22 to 0.24 mm Hg. Knee angle (lower extremity bent at the knee) and mobility were time-varying covariates in models of the relationship between backrest elevation and tissue interface pressure. CONCLUSIONS Individual factors such as patient movement and body mass index may be important elements related to risk for pressure ulcers and ventilator-associated pneumonia, and a more nuanced approach in which positioning decisions are tailored to optimize outcomes for individual patients appears warranted.
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Affiliation(s)
- Mary Jo Grap
- Mary Jo Grap is an emeritus professor and Ruth S. Burk is affiliate faculty, Adult Health and Nursing Systems Department, School of Nursing, Paul A. Wetzel is an associate professor and Anathea Pepperl is an assistant professor, Biomedical Engineering Department, School of Engineering, and Valentina Lucas is a nurse practitioner, Department of Surgery, Virginia Commonwealth University, Richmond, Virginia. Cindy L. Munro is a professor and associate dean, Research and Innovation, College of Nursing, University of South Florida, Tampa, Florida. Christine M. Schubert is an associate professor, Department of Mathematics and Statistics, Air Force Institute of Technology, Wright-Patterson Air Force Base, Dayton, Ohio.
| | - Cindy L Munro
- Mary Jo Grap is an emeritus professor and Ruth S. Burk is affiliate faculty, Adult Health and Nursing Systems Department, School of Nursing, Paul A. Wetzel is an associate professor and Anathea Pepperl is an assistant professor, Biomedical Engineering Department, School of Engineering, and Valentina Lucas is a nurse practitioner, Department of Surgery, Virginia Commonwealth University, Richmond, Virginia. Cindy L. Munro is a professor and associate dean, Research and Innovation, College of Nursing, University of South Florida, Tampa, Florida. Christine M. Schubert is an associate professor, Department of Mathematics and Statistics, Air Force Institute of Technology, Wright-Patterson Air Force Base, Dayton, Ohio
| | - Paul A Wetzel
- Mary Jo Grap is an emeritus professor and Ruth S. Burk is affiliate faculty, Adult Health and Nursing Systems Department, School of Nursing, Paul A. Wetzel is an associate professor and Anathea Pepperl is an assistant professor, Biomedical Engineering Department, School of Engineering, and Valentina Lucas is a nurse practitioner, Department of Surgery, Virginia Commonwealth University, Richmond, Virginia. Cindy L. Munro is a professor and associate dean, Research and Innovation, College of Nursing, University of South Florida, Tampa, Florida. Christine M. Schubert is an associate professor, Department of Mathematics and Statistics, Air Force Institute of Technology, Wright-Patterson Air Force Base, Dayton, Ohio
| | - Christine M Schubert
- Mary Jo Grap is an emeritus professor and Ruth S. Burk is affiliate faculty, Adult Health and Nursing Systems Department, School of Nursing, Paul A. Wetzel is an associate professor and Anathea Pepperl is an assistant professor, Biomedical Engineering Department, School of Engineering, and Valentina Lucas is a nurse practitioner, Department of Surgery, Virginia Commonwealth University, Richmond, Virginia. Cindy L. Munro is a professor and associate dean, Research and Innovation, College of Nursing, University of South Florida, Tampa, Florida. Christine M. Schubert is an associate professor, Department of Mathematics and Statistics, Air Force Institute of Technology, Wright-Patterson Air Force Base, Dayton, Ohio
| | - Anathea Pepperl
- Mary Jo Grap is an emeritus professor and Ruth S. Burk is affiliate faculty, Adult Health and Nursing Systems Department, School of Nursing, Paul A. Wetzel is an associate professor and Anathea Pepperl is an assistant professor, Biomedical Engineering Department, School of Engineering, and Valentina Lucas is a nurse practitioner, Department of Surgery, Virginia Commonwealth University, Richmond, Virginia. Cindy L. Munro is a professor and associate dean, Research and Innovation, College of Nursing, University of South Florida, Tampa, Florida. Christine M. Schubert is an associate professor, Department of Mathematics and Statistics, Air Force Institute of Technology, Wright-Patterson Air Force Base, Dayton, Ohio
| | - Ruth S Burk
- Mary Jo Grap is an emeritus professor and Ruth S. Burk is affiliate faculty, Adult Health and Nursing Systems Department, School of Nursing, Paul A. Wetzel is an associate professor and Anathea Pepperl is an assistant professor, Biomedical Engineering Department, School of Engineering, and Valentina Lucas is a nurse practitioner, Department of Surgery, Virginia Commonwealth University, Richmond, Virginia. Cindy L. Munro is a professor and associate dean, Research and Innovation, College of Nursing, University of South Florida, Tampa, Florida. Christine M. Schubert is an associate professor, Department of Mathematics and Statistics, Air Force Institute of Technology, Wright-Patterson Air Force Base, Dayton, Ohio
| | - Valentina Lucas
- Mary Jo Grap is an emeritus professor and Ruth S. Burk is affiliate faculty, Adult Health and Nursing Systems Department, School of Nursing, Paul A. Wetzel is an associate professor and Anathea Pepperl is an assistant professor, Biomedical Engineering Department, School of Engineering, and Valentina Lucas is a nurse practitioner, Department of Surgery, Virginia Commonwealth University, Richmond, Virginia. Cindy L. Munro is a professor and associate dean, Research and Innovation, College of Nursing, University of South Florida, Tampa, Florida. Christine M. Schubert is an associate professor, Department of Mathematics and Statistics, Air Force Institute of Technology, Wright-Patterson Air Force Base, Dayton, Ohio
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Batterton KA, Schubert CM. A nonparametric fiducial interval for the Youden index in multi-state diagnostic settings. Stat Med 2016; 35:78-96. [PMID: 26278275 DOI: 10.1002/sim.6613] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2013] [Revised: 06/10/2015] [Accepted: 07/14/2015] [Indexed: 12/27/2022]
Abstract
The Youden index is a commonly employed metric to characterize the performance of a diagnostic test at its optimal point. For tests with three or more outcome classes, the Youden index has been extended; however, there are limited methods to compute a confidence interval (CI) about its value. Often, outcome classes are assumed to be normally distributed, which facilitates computational formulas for the CI bounds; however, many scenarios exist for which these assumptions cannot be made. In addition, many of these existing CI methods do not work well for small sample sizes. We propose a method to compute a nonparametric interval about the Youden index utilizing the fiducial argument. This fiducial interval ensures that CI coverage is met regardless of sample size, underlying distributional assumptions, or use of a complex classifier for diagnosis. Two alternate fiducial intervals are also considered. A simulation was conducted, which demonstrates the coverage and interval length for the proposed methods. Comparisons were made using no distributional assumptions on the outcome classes and for when outcomes were assumed to be normally distributed. In general, coverage probability was consistently met, and interval length was reasonable. The proposed fiducial method was also demonstrated in data examining biomarkers in subjects to predict diagnostic stages ranging from normal kidney function to chronic allograph nephropathy. Published 2015. This article is a U.S. Government work and is in the public domain in the USA.
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Affiliation(s)
| | - Christine M Schubert
- Department of Mathematics and Statistics, Graduate School of Engineering and Management, Air Force Institute of Technology, 2950 Hobson Way, Wright-Patterson AFB, OH, 45433-7765, U.S.A
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Burk RS, Parker A, Sievers L, Rooney MB, Pepperl A, Schubert CM, Grap MJ. Effects of position and operator on high-frequency ultrasound scan quality. Intensive Crit Care Nurs 2015; 31:148-54. [PMID: 25636253 DOI: 10.1016/j.iccn.2014.11.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2014] [Revised: 11/05/2014] [Accepted: 11/08/2014] [Indexed: 10/24/2022]
Abstract
OBJECTIVES High-frequency ultrasound may evaluate those at risk for pressure ulcers. Images may be obtained by clinicians with limited training. The prone position is recommended for obtaining sacral scans but may not be feasible in the critically ill. This study investigated image quality using multiple operators and a variety of patient positions. RESEARCH METHODOLOGY Sacral scans were performed in three randomised positions in 50 volunteers by three different investigators using a 20 MHz ultrasound system. General linear models and ANOVA random effects models were used to examine the effects of operator and position on image quality rating, and measures of dermal thickness and dermal density. RESULTS The best scan for each position and operator was used for analysis (n=447 images). Image rating varied by operator (p=0.0004), although mean ratings were 3.5 or above for all operators. Dermal thickness was less for the prone position than in 90° or 60° side-lying positions (p=0.0137, p=0.0003). Dermal density was lower for the prone position than for the 90° or 60° positions (p<0.0001 for both). CONCLUSIONS These data show that overall scan quality was acceptable in all positions with all operators. However, differences were found between side-lying positions and the prone for dermal thickness and dermal density measures.
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Affiliation(s)
- Ruth S Burk
- School of Nursing, University of Texas, Health Science Center at Houston, 6901 Bertner Avenue, Houston, TX 77030, United States
| | | | - Lisa Sievers
- School of Nursing, Virginia Commonwealth University, 1100 East Leigh Street, Richmond, VA 23298-0567, United States
| | - Melissa B Rooney
- Georgia Kidney Associates, 55 Whitcher Street, Marietta, GA 30060, United States
| | - Anathea Pepperl
- School of Engineering, Virginia Commonwealth University, 601 West Main Street, Richmond, VA 23284-3068, United States
| | - Christine M Schubert
- Department of Mathematics and Statistics, Air Force Institute of Technology, 2950 Hobson Way, Wright-Patterson Air Force Base, OH 45433, United States
| | - Mary Jo Grap
- School of Nursing, Virginia Commonwealth University, 1100 East Leigh Street, Richmond, VA 23298-0567, United States.
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Grap MJ, Burk RS, Lucas V, Munro CL, Wetzel PA, Schubert CM. Use of high frequency ultrasound to detect changes in skin integrity: An image evaluation validation procedure. Intensive Crit Care Nurs 2014; 31:141-7. [PMID: 25439140 DOI: 10.1016/j.iccn.2014.08.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2014] [Revised: 08/05/2014] [Accepted: 08/23/2014] [Indexed: 11/19/2022]
Abstract
OBJECTIVES High frequency ultrasound (HFUS) scanning may be used for prevention, detection and monitoring of pressure ulcers in patients at risk and is amenable for portable, bedside use by a variety of clinicians. Limited data are available about the criteria to determine an ideal image or measures of tissue changes representative of tissue injury. We developed and evaluated criteria for overall image quality and measures of tissue integrity. METHODS In 40 mechanically ventilated adults in 3 ICUs, 241 HFUS sacral images were evaluated for agreement using criteria for overall image quality and tissue changes (dermal, hypodermal layer thickness and layer density). RESULTS HFUS sacral images (N=241) were evaluated in three analyses and showed poor agreement in all three analyses using the specific criteria for global quality, however when criteria were collapsed agreement was good to substantial. Evaluator agreement for layer thickness and layer density was also good. CONCLUSIONS A global rating is adequate for identifying good images. Agreement for measurements of layer thickness and density were also good and may be useful to identify early changes in tissue integrity leading to tissue injury. Additional data are needed concerning the association of changes in layer thickness and layer density to eventual tissue injury.
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Affiliation(s)
- Mary Jo Grap
- Adult Health and Nursing Systems, Department of the School of Nursing, Virginia Commonwealth University, Richmond, VA, United States.
| | - Ruth Srednicki Burk
- Department of Acute and Continuing Care, School of Nursing, University of Texas Health and Science Center, United States
| | - Valentina Lucas
- Department of Surgery, Virginia Commonwealth University Heath System, Richmond, VA, United States
| | - Cindy L Munro
- University of South Florida, Tampa, FL, United States
| | - Paul A Wetzel
- Biomedical Engineering Department, School of Engineering, Virginia Commonwealth University, Richmond, VA, United States
| | - Christine M Schubert
- Department of Mathematics and Statistics, Air Force Institute of Technology, Wright-Patterson Air Force Base, Dayton, OH, United States
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Schubert CM, Guennel T. Comparing Performance of Multiclass Classification Systems with ROC Manifolds: When Volume and Correct Classification Fails. COMMUN STAT-SIMUL C 2014. [DOI: 10.1080/03610918.2013.794284] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Abstract
BACKGROUND Agitation in critically ill adults is a frequent complication of hospitalization and results in multiple adverse outcomes. Potential causes of agitation are numerous; however, data on factors predictive of agitation are limited. OBJECTIVES To identify predictors of agitation by examining demographic and clinical characteristics of critically ill patients. METHODS A medical record review was performed. Documentation of agitation was indicated by scores on the Richmond Agitation-Sedation Scale or the use of an agitation keyword. Records of 200 patients from 1 medical and 1 surgical intensive care unit were used for the study. Risk factors were determined for 2 points in time: admission to the intensive care unit and within 24 hours before the first episode of agitation. Data on baseline demographics, preadmission risk factors, and clinical data were collected and were evaluated by using logistic multivariable regression to determine predictors of agitation. RESULTS Predictors of agitation on admission to intensive care were history of use of illicit substances, height, respiratory and central nervous system subscores on the Sequential Organ Failure Assessment, and use of restraints. Predictors of agitation within 24 hours before the onset of agitation were history of psychiatric diagnosis, height, score on the Sequential Organ Failure Assessment, ratio of Pao2 to fraction of inspired oxygen less than 200, serum pH, percentage of hours with restraints, percentage of hours of mechanical ventilation, pain, and presence of genitourinary catheters. CONCLUSIONS Predictors of agitation on admission and within 24 hours before the onset of agitation were primarily clinical variables.
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Affiliation(s)
- Ruth S Burk
- Ruth S. Burk is an assistant professor, Department of Acute and Continuing Care, University of Texas Health Science Center in Houston. Mary Jo Grap is the Nursing Alumni Distinguished Professor, Adult Health and Nursing Systems Department, School of Nursing, and Curtis N. Sessler is the Orhan Muren Professor of Medicine, Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Virginia Commonwealth University, Richmond, Virginia. Cindy L. Munro is an associate dean, Research and Innovation, and a professor, University of South Florida College of Nursing, Tampa, Florida. Christine M. Schubert is an associate professor, Department of Mathematics and Statistics, Air Force Institute of Technology, Wright-Patterson Air Force Base, Dayton, Ohio.
| | - Mary Jo Grap
- Ruth S. Burk is an assistant professor, Department of Acute and Continuing Care, University of Texas Health Science Center in Houston. Mary Jo Grap is the Nursing Alumni Distinguished Professor, Adult Health and Nursing Systems Department, School of Nursing, and Curtis N. Sessler is the Orhan Muren Professor of Medicine, Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Virginia Commonwealth University, Richmond, Virginia. Cindy L. Munro is an associate dean, Research and Innovation, and a professor, University of South Florida College of Nursing, Tampa, Florida. Christine M. Schubert is an associate professor, Department of Mathematics and Statistics, Air Force Institute of Technology, Wright-Patterson Air Force Base, Dayton, Ohio
| | - Cindy L Munro
- Ruth S. Burk is an assistant professor, Department of Acute and Continuing Care, University of Texas Health Science Center in Houston. Mary Jo Grap is the Nursing Alumni Distinguished Professor, Adult Health and Nursing Systems Department, School of Nursing, and Curtis N. Sessler is the Orhan Muren Professor of Medicine, Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Virginia Commonwealth University, Richmond, Virginia. Cindy L. Munro is an associate dean, Research and Innovation, and a professor, University of South Florida College of Nursing, Tampa, Florida. Christine M. Schubert is an associate professor, Department of Mathematics and Statistics, Air Force Institute of Technology, Wright-Patterson Air Force Base, Dayton, Ohio
| | - Christine M Schubert
- Ruth S. Burk is an assistant professor, Department of Acute and Continuing Care, University of Texas Health Science Center in Houston. Mary Jo Grap is the Nursing Alumni Distinguished Professor, Adult Health and Nursing Systems Department, School of Nursing, and Curtis N. Sessler is the Orhan Muren Professor of Medicine, Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Virginia Commonwealth University, Richmond, Virginia. Cindy L. Munro is an associate dean, Research and Innovation, and a professor, University of South Florida College of Nursing, Tampa, Florida. Christine M. Schubert is an associate professor, Department of Mathematics and Statistics, Air Force Institute of Technology, Wright-Patterson Air Force Base, Dayton, Ohio
| | - Curtis N Sessler
- Ruth S. Burk is an assistant professor, Department of Acute and Continuing Care, University of Texas Health Science Center in Houston. Mary Jo Grap is the Nursing Alumni Distinguished Professor, Adult Health and Nursing Systems Department, School of Nursing, and Curtis N. Sessler is the Orhan Muren Professor of Medicine, Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Virginia Commonwealth University, Richmond, Virginia. Cindy L. Munro is an associate dean, Research and Innovation, and a professor, University of South Florida College of Nursing, Tampa, Florida. Christine M. Schubert is an associate professor, Department of Mathematics and Statistics, Air Force Institute of Technology, Wright-Patterson Air Force Base, Dayton, Ohio
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Abstract
BACKGROUND Agitation is a frequent complication in critically ill adults, can result in life-threatening events for patients or care providers, and extends the hospital length of stay, thereby increasing hospital costs. OBJECTIVES To describe the incidence, onset, and temporal factors related to agitation in critically ill adults. METHODS Data were collected for the first 5 days of stay of all adult patients consecutively admitted to a medical respiratory intensive care unit and a surgical trauma intensive care unit during a 2-month period. Agitation was documented by using scores on the Richmond Agitation-Sedation Scale or notation of agitation in the medical record. The hour was used as the documentation epoch, and data were summarized by hour, 4-hour block, and day for each patient. RESULTS Data were collected on 200 patients, 100 from each unit. Among the sample, 118 (59%) were agitated at some time during the 5 days. The overall agitation rate was 7.8% of the total hourly time. Mean onset of agitation was 11.6 hours from time of admission to the unit. Of the 118 patients who were agitated at some time, 102 (86%) had agitation on day 1. Compared with patients in the surgical trauma unit, patients in the medical respiratory unit had significantly more hours of agitation the first day and first hour of admission and significantly earlier onset of agitation. CONCLUSIONS Agitation was present in more than one-half of the patients in the sample, typically developed on the first day, and involved consecutive days.
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Affiliation(s)
- Ruth S Burk
- Ruth S. Burk is an assistant professor, Department of Acute and Continuing Care, University of Texas Health Science Center School of Nursing in Houston, Texas. Mary Jo Grap is Nursing Alumni Distinguished Professor, Adult Health and Nursing Systems Department, School of Nursing, and Curtis N. Sessler is the Orhan Muren Professor of Medicine, Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Virginia Commonwealth University, Richmond, Virginia. Cindy L. Munro is associate dean for research and innovation and a professor, University of South Florida, College of Nursing, Tampa, Florida. Christine M. Schubert is an assistant professor, Department of Mathematics and Statistics, Air Force Institute of Technology, Wright-Patterson Air Force Base, Dayton, Ohio.
| | - Mary Jo Grap
- Ruth S. Burk is an assistant professor, Department of Acute and Continuing Care, University of Texas Health Science Center School of Nursing in Houston, Texas. Mary Jo Grap is Nursing Alumni Distinguished Professor, Adult Health and Nursing Systems Department, School of Nursing, and Curtis N. Sessler is the Orhan Muren Professor of Medicine, Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Virginia Commonwealth University, Richmond, Virginia. Cindy L. Munro is associate dean for research and innovation and a professor, University of South Florida, College of Nursing, Tampa, Florida. Christine M. Schubert is an assistant professor, Department of Mathematics and Statistics, Air Force Institute of Technology, Wright-Patterson Air Force Base, Dayton, Ohio
| | - Cindy L Munro
- Ruth S. Burk is an assistant professor, Department of Acute and Continuing Care, University of Texas Health Science Center School of Nursing in Houston, Texas. Mary Jo Grap is Nursing Alumni Distinguished Professor, Adult Health and Nursing Systems Department, School of Nursing, and Curtis N. Sessler is the Orhan Muren Professor of Medicine, Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Virginia Commonwealth University, Richmond, Virginia. Cindy L. Munro is associate dean for research and innovation and a professor, University of South Florida, College of Nursing, Tampa, Florida. Christine M. Schubert is an assistant professor, Department of Mathematics and Statistics, Air Force Institute of Technology, Wright-Patterson Air Force Base, Dayton, Ohio
| | - Christine M Schubert
- Ruth S. Burk is an assistant professor, Department of Acute and Continuing Care, University of Texas Health Science Center School of Nursing in Houston, Texas. Mary Jo Grap is Nursing Alumni Distinguished Professor, Adult Health and Nursing Systems Department, School of Nursing, and Curtis N. Sessler is the Orhan Muren Professor of Medicine, Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Virginia Commonwealth University, Richmond, Virginia. Cindy L. Munro is associate dean for research and innovation and a professor, University of South Florida, College of Nursing, Tampa, Florida. Christine M. Schubert is an assistant professor, Department of Mathematics and Statistics, Air Force Institute of Technology, Wright-Patterson Air Force Base, Dayton, Ohio
| | - Curtis N Sessler
- Ruth S. Burk is an assistant professor, Department of Acute and Continuing Care, University of Texas Health Science Center School of Nursing in Houston, Texas. Mary Jo Grap is Nursing Alumni Distinguished Professor, Adult Health and Nursing Systems Department, School of Nursing, and Curtis N. Sessler is the Orhan Muren Professor of Medicine, Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Virginia Commonwealth University, Richmond, Virginia. Cindy L. Munro is associate dean for research and innovation and a professor, University of South Florida, College of Nursing, Tampa, Florida. Christine M. Schubert is an assistant professor, Department of Mathematics and Statistics, Air Force Institute of Technology, Wright-Patterson Air Force Base, Dayton, Ohio
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Batterton KA, Schubert CM. Confidence intervals around Bayes Cost in multi-state diagnostic settings to estimate optimal performance. Stat Med 2014; 33:3280-99. [DOI: 10.1002/sim.6174] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2013] [Revised: 03/19/2014] [Accepted: 03/24/2014] [Indexed: 11/08/2022]
Affiliation(s)
- Katherine A. Batterton
- Department of Mathematics and Statistics, Graduate School of Engineering and Management; Air Force Institute of Technology; 2950 Hobson Way, Wright-Patterson AFB, OH 45433-7765 U.S.A
| | - Christine M. Schubert
- Department of Mathematics and Statistics, Graduate School of Engineering and Management; Air Force Institute of Technology; 2950 Hobson Way, Wright-Patterson AFB, OH 45433-7765 U.S.A
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Ahmed AE, Schubert CM, McClish DK. Reducing cost in sequential testing: a limit of indifference approach. Stat Med 2013; 32:2715-27. [PMID: 23339070 DOI: 10.1002/sim.5741] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2011] [Accepted: 12/21/2012] [Indexed: 11/08/2022]
Abstract
In noninferiority studies, a limit of indifference is used to express a tolerance in results such that the clinician would regard such results as being acceptable or 'not worse'. We applied this concept to a measure of accuracy, the Receiver Operating Characteristic (ROC) curve, for a sequence of tests. We expressed a limit of indifference for the range of acceptable sensitivity values and examined the associated cost of testing within this range. In doing so, we generated the minimum cost maximum ROC (MCMROC) curve, which reflects the reduced sensitivity and cost of testing. We compared the MCMROC and its associated cost curve between limits of indifference set to 0.999 [a 0.1% reduction in true positive rate (TPR)], 0.95 (a 5% reduction in TPR), and 1 (no reduction in TPR). The limit of indifference tended to have less of an effect on the MCMROC curves than on the associated cost curves that were greatly affected. Cost was reduced at high false positive rates (FPRs) at higher limit of indifference (0.999) and at small FPRs as the limit of indifference decreased (0.95). These patterns were also observed as applied to sequential strategies used to diagnose diabetes in the Pima Indians.
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Affiliation(s)
- Anwar E Ahmed
- Department of Epidemiology and Biostatistics, College of Public Health and Health Informatics, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
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Bajaj JS, Gillevet PM, Patel NR, Ahluwalia V, Ridlon JM, Kettenmann B, Schubert CM, Sikaroodi M, Heuman DM, Crossey MME, Bell DE, Hylemon PB, Fatouros PP, Taylor-Robinson SD. A longitudinal systems biology analysis of lactulose withdrawal in hepatic encephalopathy. Metab Brain Dis 2012; 27:205-15. [PMID: 22527995 DOI: 10.1007/s11011-012-9303-0] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2012] [Accepted: 03/23/2012] [Indexed: 12/11/2022]
Abstract
The pathogenesis of hepatic encephalopathy(HE) is unclear. However gut flora changes, inflammation and neuro-glial injury have been implicated. The aim was to evaluate factors that were associated with HE recurrence after lactulose withdrawal by analyzing the clinical phenotype, stool microbiome and systemic metabolome longitudinally. HE patients on a standard diet who were adherent on lactulose underwent characterization of their phenotype [cognition, inflammatory cytokines, in-vivo brain MR spectroscopy(MRS)], gut microbiome (stool Multitag Pyrosequencing) and metabolome (urine/serum ex-vivo MRS) analysis while on lactulose and on days 2, 14 and 30 post-withdrawal. Patients whose HE recurred post-withdrawal were compared to those without recurrence. We included seven men (53 ± 8 years) who were adherent on lactulose after a precipitated HE episode were included. HE recurred in three men 32 ± 6 days post-withdrawal. In-vivo brain MRS showed increased glutamine+glutamate (Glx) and decreased myoinositol with a reduction in stool Faecalibacterium spp., post-withdrawal. HE recurrence was predicted by poor baseline inhibitory control and block design performance and was associated with a shift of choline metabolism from tri-methylamine oxide formation towards the development of di-methylglycine, glycine and creatinine. This was accompanied by a mixed effect on the immune response (suppressed IL-10 and Th1/Th2/Th17 response). The correlation network showed Prevotella to be linked to improved cognition and decreased inflammation in patients without HE recurrence. We conclude that lactulose withdrawal results in worsening cognition, mixed inflammatory response effect, lowered stool Faecalibacterium and increase in MR-measurable brain Glx. HE recurrence post-lactulose withdrawal can be predicted by baseline cognitive performance and is accompanied by disrupted choline metabolism.
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Affiliation(s)
- Jasmohan S Bajaj
- Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, 23249, USA.
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Abstract
Homicide causes negative unintended consequences for family survivors. Family survivors face complicated grief and overwhelming loss with minimal support from others. The authors offered a retreat intervention as a way to ameliorate the effects of the homicidal death for family survivors of homicide. An exploratory longitudinal pilot study examined the feasibility and acceptability of the intervention and explored the impact of the TOZI© Healing intervention on participants' distress symptoms. Eight family members participated in the 2-day retreat and completed surveys at five time intervals over 30 months. Descriptive statistics and correlations were used to analyze the data. Although sample sizes were too small to achieve statistical significance, changes on selected holistic health outcomes, supported by overwhelmingly positive focus group responses to the intervention, affirm the need for further study.
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Affiliation(s)
- Inez Tuck
- North Carolina Agricultural and Technical State University, Greensboro, NC 27411, USA.
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Barker RT, Knisely JS, Barker SB, Cobb RK, Schubert CM. Preliminary investigation of employee's dog presence on stress and organizational perceptions. Intl J of Workplace Health Mgt 2012. [DOI: 10.1108/17538351211215366] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Sun SS, Deng X, Sabo R, Carrico R, Schubert CM, Wan W, Sabo C. Secular trends in body composition for children and young adults: the Fels Longitudinal Study. Am J Hum Biol 2012; 24:506-14. [PMID: 22410970 DOI: 10.1002/ajhb.22256] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2011] [Revised: 12/14/2011] [Accepted: 01/18/2012] [Indexed: 11/09/2022] Open
Abstract
OBJECTIVES To determine secular trends by birth decade in body mass index (BMI), waist circumference/height (W/Ht), percent body fat (PBF), and fat-free mass adjusted for height squared (FFM/Ht(2) ) in children and adolescents aged 8-18 years. METHODS Serial data were analyzed from 628 boys and 591 girls aged 8-18 years who participated in the Fels Longitudinal Study. Subjects were stratified by birth decade from 1960 to 1999. Means and standard deviations were computed for all measurements by birth decade, age, and sex. A repeated-measures analysis of variance was used data to ascertain secular trends separately for boys and girls. RESULTS Boys and girls born in the 1990s had significantly higher mean BMI, W/Ht, and PBF than did children born in previous decades. Mean FFM/Ht(2) was significantly smaller in boys born in the 1990s than boys of the same age born in earlier decades. No secular trend was noted in FFM/Ht(2) in girls by decade of birth. CONCLUSION Our analysis of serial data collected over 4 decades confirms the secular trend in childhood BMI previously observed in successive cross-sectional studies. Our analysis discloses significant positive secular trends in W/Ht and PBF in both boys and girls and a significant negative secular trend in FFM/Ht(2) in boys over the last 4 decades of the 20th century. The secular changes presage increases in the prevalence of conditions associated with childhood and adolescent obesity-such as hypertension, glucose intolerance, and dyslipidemia-that may appear as early as the second decade of life.
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Affiliation(s)
- Shumei S Sun
- Department of Biostatistics, School of Medicine, Virginia Commonwealth University, Richmond, Virginia 23298-0032, USA.
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Abstract
CONTEXT Pain is a commonly experienced and distressing symptom in women with breast cancer (BCA), and recent evidence suggests that immune activation may be associated with pain and other co-occurring symptoms. However, no studies to date have explored the relationships among perceived pain and biomarkers of inflammation in women with early-stage BCA during the initial course of treatment. OBJECTIVES The purpose of this research study was to examine the relationships among pro- and anti-inflammatory biomarkers and the presence of pain and other symptoms (anxiety, depression, fatigue, and sleep disorder) prior to induction of chemotherapy. METHOD This was a secondary analysis of data that measured perceived symptoms, including the presence of pain and pain interference, and plasma levels of pro- and anti-inflammatory cytokines and C-reactive protein (CRP) in women with early-stage BCA (N = 32) at 1 month postsurgery but prior to induction of chemotherapy. RESULTS Women experiencing pain had significantly higher levels of CRP (p < .01), interleukin (IL) 13 (p < .02), and IL-7 (p < .02) and more pain interference (p < .01), depression (p < .01), and sleep disturbance (p < .01) compared to women reporting no pain. CONCLUSION The presence of pain during the initial course of treatment in women with early-stage BCA was associated with significantly higher levels of CRP, IL-7, and IL-13, suggesting a potential role of immune activation in perceived pain. Further research to examine the precise effects of these biological factors in modulating pain is needed. Perceived pain was also associated with multiple co-occurring symptoms, and this finding has important implications for symptom management.
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Affiliation(s)
- Angela R Starkweather
- Department of Adult Health and Nursing Systems, Virginia Commonwealth University School of Nursing, Richmond, VA 23298, USA.
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Ahmed AE, McClish DK, Schubert CM. Accuracy and cost comparison in medical testing using sequential testing strategies. Stat Med 2011; 30:3416-30. [PMID: 21976377 DOI: 10.1002/sim.4358] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2010] [Accepted: 07/11/2011] [Indexed: 11/08/2022]
Abstract
The practice of sequential testing is followed by the evaluation of accuracy, but not by the evaluation of cost. This paper focuses on three logic rules for combining two sequences of tests: believe the positive (BP), which diagnoses disease if any of two tests is positive, believe the negative (BN), which diagnoses disease if any of two tests is negative, and believe the extreme (BE), which diagnoses disease if the first test is positive or, after a first inconclusive test, a second test is positive for disease. Comparisons of these strategies are provided in terms of accuracy using false positive rate, sensitivity pairs that make up the maximum receiver operating characteristic curve, and cost of testing, defined as the proportion of subjects needing two tests to diagnose disease. A method to incorporate the cost of testing into the definition of the optimal operating point is also presented. The performance of the testing strategies is examined with respect to the ratio of standard deviations and the correlation between test results under the bivariate normal assumptions. Under all parameter settings, the maximum receiver operating characteristic curve of the BE strategy never performed worse than the BN and BP strategies; the BE strategy also had the lowest cost. The use of body mass index and plasma glucose concentration to diagnose diabetes in Pima Indians was presented as a real-world application. The optimal operating points found by the BN and BE strategies produce lower false positive rate values than the BP strategy for these data.
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Affiliation(s)
- Anwar E Ahmed
- Advanced Analytics Department, King Abdullah International Medical Research Center, National Guard Health Affairs, Riyadh, Saudi Arabia
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Bajaj JS, Saeian K, Schubert CM, Franco R, Franco J, Heuman DM. Disruption of sleep architecture in minimal hepatic encephalopathy and ghrelin secretion. Aliment Pharmacol Ther 2011; 34:103-5. [PMID: 21631553 DOI: 10.1111/j.1365-2036.2011.04681.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Lyon DE, Walter JM, Starkweather AR, Schubert CM, McCain NL. Tryptophan degradation in women with breast cancer: a pilot study. BMC Res Notes 2011; 4:156. [PMID: 21615916 PMCID: PMC3117722 DOI: 10.1186/1756-0500-4-156] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2011] [Accepted: 05/26/2011] [Indexed: 12/24/2022] Open
Abstract
Background Altered tryptophan metabolism and indoleamine 2,3-dioxygenase activity are linked to cancer development and progression. In addition, these biological factors have been associated with the development and severity of neuropsychiatric syndromes, including major depressive disorder. However, this biological mechanism associated with both poor disease outcomes and adverse neuropsychiatric symptoms has received little attention in women with breast cancer. Therefore, a pilot study was undertaken to compare levels of tryptophan and other proteins involved in tryptophan degradation in women with breast cancer to women without cancer, and secondarily, to examine levels in women with breast caner over the course of chemotherapy. Findings Blood samples were collected from women with a recent diagnosis of breast cancer (n = 33) before their first cycle of chemotherapy and after their last cycle of chemotherapy. The comparison group (n = 24) provided a blood sample prior to breast biopsy. Plasma concentrations of tryptophan, kynurenine, and tyrosine were determined. The kynurenine to tryptophan ratio (KYN/TRP) was used to estimate indoleamine 2,3-dioxygenase activity. On average, the women with breast cancer had lower levels of tryptophan, elevated levels of kynurenine and tyrosine and an increased KYN/TRP ratio compared to women without breast cancer. There was a statistically significant difference between the two groups in the KYN/TRP ratio (p = 0.036), which remained elevated in women with breast cancer throughout the treatment trajectory. Conclusions The findings of this pilot study suggest that increased tryptophan degradation may occur in women with early-stage breast cancer. Given the multifactorial consequences of increased tryptophan degradation in cancer outcomes and neuropsychiatric symptom manifestation, this biological mechanism deserves broader attention in women with breast cancer.
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Affiliation(s)
- Debra E Lyon
- Department of Family and Community Health Nursing, Virginia Commonwealth University School of Nursing, 1100 East Leigh Street, Richmond, Virginia, 23298, USA.
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Lyon D, Walter J, Munro CL, Schubert CM, McCain NL. Challenges in interpreting cytokine biomarkers in biobehavioral research: a breast cancer exemplar. Biol Res Nurs 2011; 13:25-31. [PMID: 21199813 DOI: 10.1177/1099800410383304] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
PURPOSE This report extends the findings of a prior study comparing the level of plasma cytokines in women with breast cancer to those of women with a benign breast biopsy with the addition of a normal comparison group. The results of this three-group comparison are presented as background for discussing several methodologic challenges for biobehavioral research in inflammatory-based conditions. METHOD This study used a descriptive, cross-sectional design to compare the levels of plasma cytokines in women with breast cancer, women with a benign breast biopsy, and a normal comparison group. The levels of 17 cytokines were measured using multiplex bead array assays (Bio-Plex®). Data analysis included a variety of descriptive and graphical techniques to illustrate between-group differences in cytokine profiles. RESULTS The levels of plasma cytokines in the sample of 35 women who had recently been diagnosed with breast cancer, 24 women with a suspicious breast mass, who subsequently were found to have a benign breast biopsy, and 33 women in a normal comparison group present a background for discussing the implications of extreme between-group differences for biobehavioral nursing research. Both the levels of individual cytokines and their patterns were distinctly different in the three groups. CONCLUSION The exemplar presented from the three-group comparison has implications for planning biobehavioral nursing research in patients with conditions characterized by inflammation.
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Affiliation(s)
- Debra Lyon
- Department of Family and Community Health Nursing, Virginia Commonwealth University School of Nursing, Richmond, VA 23298, USA.
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Matthews CA, Schubert CM, Woodward AP, Gill EJ. Variance in abdominal wall anatomy and port placement in women undergoing robotic gynecologic surgery. J Minim Invasive Gynecol 2010; 17:583-6. [PMID: 20598650 DOI: 10.1016/j.jmig.2010.04.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2009] [Revised: 03/31/2010] [Accepted: 04/23/2010] [Indexed: 11/16/2022]
Abstract
STUDY OBJECTIVES To estimate whether variability in the size and ratios of the lower and upper abdomen exist in women undergoing robotic gynecologic surgery and whether demographic variables are significantly associated, and to determine the association between abdominal wall dimensions and supraumbilical robotic port placement. DESIGN Prospective cohort study (Canadian Task Force classification II-2). SETTING University teaching hospital. PATIENTS Seventy-eight women undergoing robotic surgery between May 2008 and March 2009. INTERVENTION Measurements from the symphysis pubis to the umbilicus (lower abdomen), umbilicus to the xyphoid process (upper abdomen), and distance between the anterior superior iliac crests were obtained at surgery. A multiple linear regression model was created to determine the relationships between abdominal wall measurements, demographic variables, and need for supraumbilical robotic port placement. MEASUREMENTS AND MAIN RESULTS Fifty-six white and 22 black women were enrolled. Mean lower abdominal length was significantly affected by body mass index (BMI) (p <.001) and race (p = .006), with white women having longer measurements (17.1 cm vs 15 cm). Mean lower abdominal width was independent of age (p = .95) or race (p = .98), but was significantly correlated with BMI (p <.001). Mean upper abdominal length correlated with BMI (p <.001) and age (p = .03) but not race (p = .13). Ratios of bottom to top were significantly affected by race (p = .002) and age (p = .008) but not BMI (p = .07). Adjustments to port placement above the umbilicus were made in 44 of the 74 women (59.5%). Those who required supraumbilical port placement had a significantly shorter mean (SD) distance between the symphysis pubis and the umbilicus (14.99 [1.36] vs 18.55 [2.21]; p <.001). CONCLUSIONS Significant variability in abdominal wall anatomy exists in women undergoing robotic gynecologic surgery, and the need for supraumbilical robotic port placement is common.
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Affiliation(s)
- Catherine A Matthews
- Department of Obstetrics and Gynecology, Virginia Commonwealth University Medical Center, Richmond, VA 23298, USA.
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Bajaj JS, Schubert CM, Heuman DM, Wade JB, Gibson DP, Topaz A, Saeian K, Hafeezullah M, Bell DE, Sterling RK, Stravitz RT, Luketic V, White MB, Sanyal AJ. Persistence of cognitive impairment after resolution of overt hepatic encephalopathy. Gastroenterology 2010; 138:2332-40. [PMID: 20178797 PMCID: PMC2883684 DOI: 10.1053/j.gastro.2010.02.015] [Citation(s) in RCA: 210] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2009] [Revised: 01/28/2010] [Accepted: 02/11/2010] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS In patients with cirrhosis, hepatic encephalopathy (HE) has acute but reversible as well as chronic components. We investigated the extent of residual cognitive impairment following clinical resolution of overt HE (OHE). METHODS Cognitive function of cirrhotic patients was evaluated using psychometric tests (digit symbol, block design, and number connection [NCT-A and B]) and the inhibitory control test (ICT). Improvement (reduction) in ICT lures and first minus second halves (DeltaL(1-2)) were used to determine learning of response inhibition. Two cross-sectional studies (A and B) compared data from stable cirrhotic patients with or without prior OHE. We then prospectively assessed cognitive performance, before and after the first episode of OHE. RESULTS In study A (226 cirrhotic patients), 54 had experienced OHE, 120 had minimal HE, and 52 with no minimal HE. Despite normal mental status on lactulose after OHE, cirrhotic patients were cognitively impaired, based on results from all tests. Learning of response inhibition (DeltaL(1-2) > or =1) was evident in patients with minimal HE and no minimal HE but was lost after OHE. In study B (50 additional patients who developed > or =1 documented OHE episode during follow-up), the number of OHE hospitalizations correlated with severity of residual impairment, indicated by ICT lures (r = 0.5, P = .0001), digit symbol test (r = -0.39, P = .002), and number connection test-B (r = 0.33, P = .04). In the prospective study (59 cirrhotic patients without OHE), 15 developed OHE; ICT lure response worsened significantly after OHE (12 before vs 18 after, P = .0003), and learning of response inhibition was lost. The 44 patients who did not experience OHE did not have deteriorations in cognitive function in serial testing. CONCLUSIONS In cirrhosis, episodes of OHE are associated with persistent and cumulative deficits in working memory, response inhibition, and learning.
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Affiliation(s)
- Jasmohan S Bajaj
- Division of Gastroenterology, Hepatology, and Nutrition, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, Virginia 23249, USA.
| | - Christine M Schubert
- Biostatistics, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, VA
| | - Douglas M Heuman
- Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, VA
| | - James B Wade
- Psychology, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, VA
| | - Douglas P Gibson
- Psychology, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, VA
| | - Allyne Topaz
- Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, VA
| | - Kia Saeian
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, WI
| | - Muhammad Hafeezullah
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, WI
| | - Debulon E Bell
- Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, VA
| | - Richard K Sterling
- Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, VA
| | - R Todd Stravitz
- Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, VA
| | - Velimir Luketic
- Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, VA
| | - Melanie B White
- Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, VA
| | - Arun J Sanyal
- Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, VA
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Bajaj JS, Schubert CM, Heuman DM, Wade JB, Gibson DP, Topaz A, Saeian K, Hafeezullah M, Bell DE, Sterling RK, Stravitz RT, Luketic V, White MB, Sanyal AJ. Persistence of cognitive impairment after resolution of overt hepatic encephalopathy. Gastroenterology 2010. [PMID: 20178797 DOI: 10.1038/ajg.2011.490] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND & AIMS In patients with cirrhosis, hepatic encephalopathy (HE) has acute but reversible as well as chronic components. We investigated the extent of residual cognitive impairment following clinical resolution of overt HE (OHE). METHODS Cognitive function of cirrhotic patients was evaluated using psychometric tests (digit symbol, block design, and number connection [NCT-A and B]) and the inhibitory control test (ICT). Improvement (reduction) in ICT lures and first minus second halves (DeltaL(1-2)) were used to determine learning of response inhibition. Two cross-sectional studies (A and B) compared data from stable cirrhotic patients with or without prior OHE. We then prospectively assessed cognitive performance, before and after the first episode of OHE. RESULTS In study A (226 cirrhotic patients), 54 had experienced OHE, 120 had minimal HE, and 52 with no minimal HE. Despite normal mental status on lactulose after OHE, cirrhotic patients were cognitively impaired, based on results from all tests. Learning of response inhibition (DeltaL(1-2) > or =1) was evident in patients with minimal HE and no minimal HE but was lost after OHE. In study B (50 additional patients who developed > or =1 documented OHE episode during follow-up), the number of OHE hospitalizations correlated with severity of residual impairment, indicated by ICT lures (r = 0.5, P = .0001), digit symbol test (r = -0.39, P = .002), and number connection test-B (r = 0.33, P = .04). In the prospective study (59 cirrhotic patients without OHE), 15 developed OHE; ICT lure response worsened significantly after OHE (12 before vs 18 after, P = .0003), and learning of response inhibition was lost. The 44 patients who did not experience OHE did not have deteriorations in cognitive function in serial testing. CONCLUSIONS In cirrhosis, episodes of OHE are associated with persistent and cumulative deficits in working memory, response inhibition, and learning.
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Affiliation(s)
- Jasmohan S Bajaj
- Division of Gastroenterology, Hepatology, and Nutrition, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, Virginia 23249, USA.
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Chen C, Hill LD, Schubert CM, Strauss JF, Matthews CA. Is laminin gamma-1 a candidate gene for advanced pelvic organ prolapse? Am J Obstet Gynecol 2010; 202:505.e1-5. [PMID: 20223449 DOI: 10.1016/j.ajog.2010.01.014] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2009] [Revised: 10/21/2009] [Accepted: 01/12/2010] [Indexed: 02/03/2023]
Abstract
OBJECTIVE We sought to determine allele frequencies of 3 LAMC1 single nucleotide polymorphisms (SNPs) in Caucasian and African American (AA) women with stage>II pelvic organ prolapse (POP) (cases) and in ethnicity-matched controls with stage<II POP. We also sought to determine if LAMC1 is associated with POP within ethnic groups. STUDY DESIGN Allelic discrimination was performed for LAMC1 SNPs rs10911193 (C/T), rs20563 (A/G), and rs20558 (T/C). SNP and haplotype-specific tests were used to examine associations among POP, ethnicity, and LAMC1. RESULTS In all, 411 women were enrolled. Significant differences in allele and haplotype frequencies existed among AAs and Caucasians: rs10911193 "T" (P=.0014); rs20563 "G" (P<.0001); rs20558 "C" (P<.0001); rs20563, rs20558 "GC" (P<.0001); and rs20563, rs20558 "AT" (P<.0001). No significant associations between POP and LAMC1 SNPs or haplotypes were found within ethnicities. CONCLUSION While significant differences were identified between AA and Caucasian women, no associations were found between any LAMC1 gene variant and advanced POP.
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Affiliation(s)
- Chen Chen
- Department of Obstetrics and Gynecology, Virginia Commonwealth University Medical Center, Richmond, VA, USA
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Abstract
PURPOSE To determine the relationship of abdominal circumference with increased left ventricular mass (LVM) from young adulthood into old age. METHODS Cross-sectional echocardiographic images were taken from 182 men and 220 women in the Fels Longitudinal Study 20 to 75 years of age to determine left ventricular mass. Left ventricular mass was divided by stature raised to the power of 2.7 (LVM/ht2.7) in order to minimize the impact of heart size variation from body size without overcompensating for the adverse effect of obesity. Abdominal circumference was measured and BMI calculated from stature and weight and categories of overweight, obesity and abdominal obesity were determined using published cut points. Regression models were used to describe the relationships of age, abdominal circumference, BMI and self-reported physical activity to LVM/ht2.7. RESULTS Age, abdominal circumference and BMI were each positively and significantly related to an increased LVM/ht2.7 in men and women (p < 0.05). In the men, multivariate models indicated that abdominal circumference and BMI were both significantly related to an increased LVM/ht2.7, but the inclusion of BMI in these models for the women reduced the association of abdominal circumference and physical activity below significant levels. In the men, there was also a quadratic association of abdominal circumference with LVM/ht2.7 that was significant along with BMI and physical activity. Sex-specific logistic regressions with BMI and abdominal circumference obesity categories did not change or improve the initial findings in men or women. CONCLUSIONS In women, increases in abdominal fatness as reflected in abdominal circumference at any age are linearly related to an increase in LVM/ht2.7, but the relationship of overall fatness as reflected in BMI with LVM/ht2.7 is stronger. In men, both abdominal fatness and overall fatness at any age are linearly related to an increase LVM/ht2.7. However, the significant curvilinear association of abdominal circumference and a linear association of BMI and physical activity with LVM/ht2.7 indicate the possible positive covariate relationship of overall muscle mass with LVM/ht2.7. This reflects the physiological changes with age and demonstrate, in part, the complexity of the interpretations of the inter associations of body composition, the cardiovascular system and the aging process, but the impact among the elderly and the known inadequacy of BMI at these ages remains an area for continued clinical study.
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Affiliation(s)
- W C Chumlea
- Departments of Community Health and Pediatrics, Lifespan Health Research Center, Wright State University Boonshoft School of Medicine, Dayton, OH 45420, 937-775-1428, USA.
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Bajaj JS, Saeian K, Schubert CM, Hafeezullah M, Franco J, Varma RR, Gibson DP, Hoffmann RG, Stravitz RT, Heuman DM, Sterling RK, Shiffman M, Topaz A, Boyett S, Bell D, Sanyal AJ. Minimal hepatic encephalopathy is associated with motor vehicle crashes: the reality beyond the driving test. Hepatology 2009; 50:1175-83. [PMID: 19670416 PMCID: PMC2757520 DOI: 10.1002/hep.23128] [Citation(s) in RCA: 225] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
UNLABELLED Patients with minimal hepatic encephalopathy (MHE) have impaired driving skills, but association of MHE with motor vehicle crashes is unclear. Standard psychometric tests (SPT) or inhibitory control test (ICT) can be used to diagnose MHE. The aim was to determine the association of MHE with crashes and traffic violations over the preceding year and on 1-year follow-up. Patients with cirrhosis were diagnosed with MHE by ICT (MHEICT) and SPT (MHESPT). Self and department-of-transportation (DOT)-reports were used to determine crashes and violations over the preceding year. Agreement between self and DOT-reports was analyzed. Patients then underwent 1-year follow-up for crash/violation occurrence. Crashes in those with/without MHEICT and MHESPT were compared. 167 patients with cirrhosis had DOT-reports, of which 120 also had self-reports. A significantly higher proportion of MHEICT patients with cirrhosis experienced crashes in the preceding year compared to those without MHE by self-report (17% vs 0.0%, P = 0.0004) and DOT-reports (17% vs 3%, P = 0.004, relative risk: 5.77). SPT did not differentiate between those with/without crashes. A significantly higher proportion of patients with crashes had MHEICT compared to MHESPT, both self-reported (100% vs 50%, P = 0.03) and DOT-reported (89% vs 44%, P = 0.01). There was excellent agreement between self and DOT-reports for crashes and violations (Kappa 0.90 and 0.80). 109 patients were followed prospectively. MHEICT patients had a significantly higher future crashes/violations compared to those without (22% vs 7%, P = 0.03) but MHESPT did not. MHEICT (Odds ratio: 4.51) and prior year crash/violation (Odds ratio: 2.96) were significantly associated with future crash/violation occurrence. CONCLUSION Patients with cirrhosis and MHEICT have a significantly higher crash rate over the preceding year and on prospective follow-up compared to patients without MHE. ICT, but not SPT performance is significantly associated with prior and future crashes and violations. There was an excellent agreement between self- and DOT-reports.
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Affiliation(s)
- Jasmohan S Bajaj
- Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, VA 23221, USA.
| | - Kia Saeian
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, WI
| | - Christine M Schubert
- Department of Biostatistics, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, VA
| | - Muhammad Hafeezullah
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, WI
| | - Jose Franco
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, WI
| | - Rajiv R Varma
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, WI
| | - Douglas P Gibson
- Division of Psychology, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, VA
| | | | - R Todd Stravitz
- Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, VA
| | - Douglas M Heuman
- Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, VA
| | - Richard K Sterling
- Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, VA
| | - Mitchell Shiffman
- Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, VA
| | - Allyne Topaz
- Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, VA
| | - Sherry Boyett
- Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, VA
| | - Debulon Bell
- Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, VA
| | - Arun J Sanyal
- Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, VA
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Abstract
OBJECTIVE To estimate sensitivity, specificity, and positive and negative predictive values of components of the metabolic syndrome (MetS) during childhood for MetS and type 2 diabetes (T2D) in adulthood. STUDY DESIGN Data from 3 major studies-the Fels Longitudinal Study, the Muscatine Study, and the Princeton Follow-up Study-were combined to examine how thresholds of metabolic components during childhood determine adult MetS and T2D. Available metabolic components examined in the 1789 subjects included high-density lipoprotein, triglyceride levels, glucose, and percentiles for body mass index, waist circumference, triglycerides, and systolic and diastolic blood pressures. Sensitivity, specificity, and positive and negative predictive values for a refined set of component threshold values were examined individually and in combination. RESULTS Sensitivity and positive predictive values remained low for adult MetS and T2D for individual components. However, specificity and negative predictive values were fairly high for MetS and exceptionally so for T2D. In combination, having 1 or more of the components showed the highest sensitivity over any individual component and high negative predictive value. Overall, specificity and negative predictive values remained high whether considering individual or combined components for T2D. CONCLUSIONS Sensitivity and positive predictive values on the basis of childhood measures remained relatively low, but specificity and negative predictive values were consistently higher, especially for T2D. This indicates that these components, when examined during childhood, may provide a useful screening approach to identifying children not at risk so that further attention can be focused on those who may be in need of future intervention.
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Affiliation(s)
- Christine M Schubert
- Department of Biostatistics, School of Medicine, Virginia Commonwealth University, Richmond, VA 23298-0032, USA.
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Abstract
OBJECTIVES To ascertain the influence of such a prolonged juvenile state on delaying the onset of the metabolic syndrome, cardiovascular disease, and type 2 diabetes mellitus later in life. STUDY DESIGN We define prolongation of a juvenile state as a retarded tempo of growth, determined by the timing of peak height velocity in each subject and relate the retarded tempo of growth to metabolic syndrome, cardiovascular disease, and type 2 diabetes mellitus later in life by use of serial data of 237 study participants (119 men and 118 women) enrolled in the Fels Longitudinal study. RESULTS Children who matured early tended to have greater body mass index, waist circumference, and percent of body fat and were more likely to have adverse cardiovascular risk profiles than children who matured late. The differences in these risk factors between early and late maturers were significant for percent body fat, fasting plasma triglycerides, and fasting plasma insulin. CONCLUSIONS The analyses disclosed a clear separation between early and late maturers in the appearance of these risk factors in young adulthood.
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Affiliation(s)
- Shumei S Sun
- Department of Biostatistics, School of Medicine, Virginia Commonwealth University, Richmond, VA 23298-0032, USA.
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Schubert CM, Cook S, Sun SS, Huang TTK. Additive utility of family history and waist circumference to body mass index in childhood for predicting metabolic syndrome in adulthood. J Pediatr 2009; 155:S6.e9-13. [PMID: 19732567 PMCID: PMC3988675 DOI: 10.1016/j.jpeds.2009.05.024] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2009] [Revised: 12/18/2009] [Accepted: 12/18/2009] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To determine whether waist circumference (WC) and family history of disease increase the predictive utility of body mass index (BMI) for adult metabolic syndrome (MetS). STUDY DESIGN A subsample of 161 men and women from the Fels Longitudinal Study with childhood and adulthood measures were analyzed. Using logistic regression, childhood BMI categories (50th, 75th, and 85th percentiles), WC categories (75th and 90th percentiles), and family history of type 2 diabetes mellitus or cardiovascular disease were modeled separately and in combinations to predict adult MetS. Predicted probabilities and c-statistics were compared across models. RESULTS The addition of family history to BMI improved the predicted probability of adult MetS from 29% to 52% (Deltac-statistic = 0.13). The combination of WC and BMI was more predictive than BMI alone but did not outperform the combination of family history and BMI. In 3 of the 4 models with a combination of family history, WC, and BMI, the predicted probability of adult MetS did not exceed that from the combination of family history and BMI. CONCLUSIONS Family history of type 2 diabetes or cardiovascular disease is a useful addition to BMI in childhood to predict the future risk of adult MetS.
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Affiliation(s)
- Christine M Schubert
- Department of Biostatistics, School of Medicine and Emerging School of Public Health, Virginia Commonwealth University, Richmond, VA, USA
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Pérez FJ, Schubert CM, Parvez B, Pathak V, Ellenbogen KA, Wood MA. Long-Term Outcomes After Catheter Ablation of Cavo-Tricuspid Isthmus Dependent Atrial Flutter. Circ Arrhythm Electrophysiol 2009; 2:393-401. [PMID: 19808495 DOI: 10.1161/circep.109.871665] [Citation(s) in RCA: 208] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Despite the success of catheter ablation of cavotricuspid isthmus–dependent atrial flutter (AFL), important postablation outcomes are ill-defined. The purpose of our study was to analyze long-term outcomes after catheter ablation of cavotricuspid isthmus–dependent AFL.
Methods and Results—
A meta-analysis was performed of articles reporting clinical outcomes after catheter ablation of AFL published between January 1988 and July 2008. The analysis included 158 studies comprising 10 719 patients (79% men, 59.8�0.5 years old, 46% left atrial enlargement, 46% heart disease, 42% with history of atrial fibrillation, 14.3�0.4 months of follow-up). The overall acute success rate adjusted for reporting bias was 91.1% (95% CI, 89.5 to 92.4), 92.7% (95% CI, 90.0 to 94.8) for 8- to 10-mm tip/or irrigated radiofrequency catheters, and 87.9% (95% CI, 84.2 to 90.9) for 4- to 6-mm tip catheters (
P
>0.05). Atrial flutter recurrence rates were significantly reduced by use of 8- to 10-mm tip or irrigated radiofrequency catheters (6.7% versus 13.8%,
P
<0.05) and by use of bidirectional cavotricuspid isthmus block as a procedural end point (9.3% versus 23.6%,
P
<0.05). The AFL recurrence rate did not increase over time. The overall occurrence rate of atrial fibrillation after AFL ablation was 33.6% (95% CI, 29.7 to 37.3) but was 52.7% (95% CI, 47.8 to 57.6) in patients with a history of atrial fibrillation before ablation and 23.1% (95% CI, 17.5 to 29.9) in those without atrial fibrillation before ablation (
P
<0.05). The incidence of atrial fibrillation increased over time in both groups; however, 5 years after ablation, the incidence of atrial fibrillation was similar in those with and without atrial fibrillation before ablation. The acute complication rate was 2.6% (95% CI, 2 to 3). The mortality rate during follow-up was 3.3% (95% CI, 2.4 to 4.5). Antiarrhythmic drug use after ablation was 31.6% (95% CI, 25.6 to 37.8). The long-term use of coumadin was 65.9%, (95% CI, 43.8 to 82.8). Quality of life data were very limited.
Conclusions—
AFL ablation is safe and effective. Ablation technology and procedural end points have greater influences on AFL recurrences than on acute ablation success rates. Atrial fibrillation is common after AFL ablation. Almost one third of patients take antiarrhythmic drugs after AFL ablation. Atrial fibrillation before AFL ablation may indicate a more advanced state of electric disease.
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Affiliation(s)
- Francisco J. Pérez
- From the Division of Cardiology (F.J.P., B.P., V.P., K.A.E., M.A.W.) and the Department of Biostatistics (C.M.S.), Virginia Commonwealth University Medical Center, Richmond, Va
| | - Christine M. Schubert
- From the Division of Cardiology (F.J.P., B.P., V.P., K.A.E., M.A.W.) and the Department of Biostatistics (C.M.S.), Virginia Commonwealth University Medical Center, Richmond, Va
| | - Babar Parvez
- From the Division of Cardiology (F.J.P., B.P., V.P., K.A.E., M.A.W.) and the Department of Biostatistics (C.M.S.), Virginia Commonwealth University Medical Center, Richmond, Va
| | - Vishesh Pathak
- From the Division of Cardiology (F.J.P., B.P., V.P., K.A.E., M.A.W.) and the Department of Biostatistics (C.M.S.), Virginia Commonwealth University Medical Center, Richmond, Va
| | - Kenneth A. Ellenbogen
- From the Division of Cardiology (F.J.P., B.P., V.P., K.A.E., M.A.W.) and the Department of Biostatistics (C.M.S.), Virginia Commonwealth University Medical Center, Richmond, Va
| | - Mark A. Wood
- From the Division of Cardiology (F.J.P., B.P., V.P., K.A.E., M.A.W.) and the Department of Biostatistics (C.M.S.), Virginia Commonwealth University Medical Center, Richmond, Va
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Bajaj JS, Hafeezullah M, Zadvornova Y, Martin E, Schubert CM, Gibson DP, Hoffmann RG, Sanyal AJ, Heuman DM, Hammeke TA, Saeian K. The effect of fatigue on driving skills in patients with hepatic encephalopathy. Am J Gastroenterol 2009; 104:898-905. [PMID: 19277025 DOI: 10.1038/ajg.2009.7] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Hepatic encephalopathy, both overt (OHE) and minimal (MHE), is associated with poor quality of life and fatigue. The aim of this study was to define the effect of fatigue on driving skills in MHE and OHE patients. METHODS Cirrhotics and age/education-matched controls were administered a psychometric battery of tests to diagnose MHE. Cirrhotics with recent OHE on lactulose were also included. All subjects underwent a driving simulation; to assess fatigue, the second half performance was compared with the first half of the simulation. The outcomes were collisions, speeding, road excursions, and center crossings. Actual driving-associated fatigue was assessed by the American Medical Association (AMA) driver survey. RESULTS A total of 100 cirrhotics (51 MHE, 27 no MHE, and 22 OHE) and 67 controls were included. A significantly higher proportion of OHE and MHE patients admitted to fatigue after actual driving on the AMA survey compared with no MHE patients (P=0.02). All patients who admitted to fatigue and none who denied fatigue on the AMA survey had simulator collisions. Psychometric and simulator performance in treated OHE patients was similarly impaired to MHE patients despite therapy. Within groups, a significant increase in collisions, speeding, and center crossings in the second half (P=0.01) was seen only in MHE patients. CONCLUSIONS Psychometric and simulator performance in patients with recent OHE on treatment is similarly impaired as that of untreated MHE patients. Simulator performance in MHE worsens over time with fatigue. OHE and MHE patients had a higher rate of actual driving-associated fatigue on the AMA survey, which was significantly predictive of simulator collisions.
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Affiliation(s)
- Jasmohan S Bajaj
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, Virginia 23249, USA.
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Baldassari CM, Schmidt C, Schubert CM, Srinivasan P, Dodson KM, Sismanis A. Receptive language outcomes in children after cochlear implantation. Otolaryngol Head Neck Surg 2009; 140:114-9. [PMID: 19130973 DOI: 10.1016/j.otohns.2008.09.008] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2007] [Revised: 09/09/2008] [Accepted: 09/09/2008] [Indexed: 02/08/2023]
Abstract
OBJECTIVES The objectives of the present study were (1) to assess receptive language scores in children after cochlear implantation and compare them with scores in normal hearing children and children with hearing loss that use hearing aids and (2) to determine how demographic factors, such as age of implantation, impact language outcomes. STUDY DESIGN Case series. SUBJECTS/METHODS Receptive language scores in children with profound prelingual hearing loss who received cochlear implants between 1996 and 2004 were analyzed. RESULTS Standardized language assessments were available for 36 children. The average age at implantation was 33 months. The mean language scores for implanted children were within 1 standard deviation of scores of normal hearing individuals. Children with cochlear implants had significantly higher subtest scores (P < 0.05) than children with hearing aids. Children with additional disabilities had significantly (P < 0.05) poorer language performance. CONCLUSIONS Pediatric cochlear implant recipients acquire receptive language skills that approach those of their hearing peers and exceed those of children with hearing aids.
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Affiliation(s)
- Cristina M Baldassari
- Department of Otolaryngology-Head and Neck Surgery, Virginia Commonwealth University Medical Center, Richmond, VA 23298, USA.
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Jablonski RA, Munro CL, Grap MJ, Schubert CM, Ligon M, Spigelmyer P. Mouth care in nursing homes: knowledge, beliefs, and practices of nursing assistants. Geriatr Nurs 2008; 30:99-107. [PMID: 19345849 DOI: 10.1016/j.gerinurse.2008.06.010] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2008] [Revised: 05/25/2008] [Accepted: 06/01/2008] [Indexed: 02/06/2023]
Abstract
UNLABELLED The purpose of this study was to examine the knowledge, beliefs, and practices of nursing assistants (NAs) providing oral hygiene care to frail elders in nursing homes, with the intent of developing an educational program for NAs. METHODS The study occurred in two economically and geographically diverse nursing homes. From a sample size of 202 NAs, 106 returned the 19-item Oral Care Survey. RESULTS The NAs reported satisfactory knowledge regarding the tasks associated with providing mouth care. The NAs believed that tooth loss was a natural consequence of aging. They reported that they provided mouth care less frequently than is optimal but cited challenges such as caring for persons exhibiting care-resistive behaviors, fear of causing pain, and lack of supplies. CONCLUSION Nurses are in a powerful position to support NAs in providing mouth care by ensuring that they have adequate supplies and knowledge to respond to resistive behaviors.
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Affiliation(s)
- Rita A Jablonski
- School of Nursing, College of Health and Human Development, The Pennsylvania State University, University Park, PA, USA
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Parvez B, Pathak V, Schubert CM, Wood M. Comparison of lesion sizes produced by cryoablation and open irrigation radiofrequency ablation catheters. J Cardiovasc Electrophysiol 2008; 19:528-34. [PMID: 18284508 DOI: 10.1111/j.1540-8167.2007.01072.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
INTRODUCTION The relative lesion sizes created by large electrode cryoablation catheter and irrigated radiofrequency (RF) ablation are not known. The purpose of this study was to directly compare lesion sizes created by cryoablation and irrigated RF under controlled conditions. METHODS AND RESULTS Ablation lesions were created in freshly harvested porcine left ventricular myocardium in a blood-filled tissue bath using an 8-mm-tip cryoablation catheter and a 3.5-mm-tip open-irrigated RF ablation catheter. Lesions were created under all permutations of the following conditions: electrode orientation vertical (perpendicular) or horizontal (parallel) to the tissue, electrode contact pressure at 6 or 20 g, and blood flow at 0.2 or 0.4 m/s over the electrode-tissue interface. The largest lesion volumes created with cryoablation were 961 +/- 103 mm(3), compared with the largest lesions volumes created with RF of 680 +/- 48 mm(3) (P < 0.001). The 3-way interactions among electrode orientation, contact pressure, and superfusate blood velocity accounted for the variation in lesion volumes for both catheters (both r(2)= 0.97, both P < 0.0001). The greater contact pressure increased lesion size for both cryoablation and RF. For cryoablation, lesion sizes were increased by the horizontal orientation and by the lower blood flow velocity. For open-irrigated RF, lesion sizes were significantly reduced by the horizontal orientation, however. CONCLUSIONS Depending on conditions of electrode orientation, contact pressure, and blood velocity, either 8-mm-tip cryoablation or open-irrigated RF may produce the larger lesion volumes. Open-irrigated RF lesion sizes are reduced in the horizontal catheter orientation.
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Affiliation(s)
- Babar Parvez
- Division of Cardiology, Virginia Commonwealth University Medical Center, Richmond, Virginia 23298-0053, USA
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Abstract
INTRODUCTION There are no methods in clinical use to assess tissue cooling during catheter cryoablation. Cryoablation electrode temperature may be a poor predictor of lesion size. The purpose of this study was to determine whether the time necessary for the cryoablation electrode to cool to target temperature or to rewarm after cryoablation can predict lesion size. METHODS AND RESULTS Cryoablation was performed on live porcine left ventricle in a saline bath (37 degrees C) using 8-mm-tip catheter. Cryoablation was given for 300 seconds under all permutations of the following conditions: electrode orientation vertical or horizontal, contact pressure 6 or 20 g, superfusate flow over electrode-tissue interface at 0.2 or 0.4 m/s (N = 10 each condition set, total 80 experiments). The time intervals necessary to cool the electrode to the target temperature of -75 degrees C and to rewarm to + 30 degrees C after termination of cryoablation were recorded. Lesion volume was predicted best by the time necessary to rewarm the electrode to +30 degrees C (r2 = 0.65, P < 0.0001), followed by electrode temperature (r2 = 0.28, P < 0.0001) and time to cool the electrode to -75 degrees C (r2 = 0.24, P < 0.0001). Time to +30 degrees C and time to -75 degrees C were associated with superfusate flow rate, contact pressure, and electrode orientation (r2 = 0.80 and 0.61, respectively, both P < 0.0001). Superfusate flow rate, contact pressure, and orientation were also highly predictive of lesion volume (r2 = 0.93, P < 0.0001). CONCLUSIONS Time to cryoablation electrode rewarming is a better predictor of cryoablation lesion size than is electrode temperature. Time to cryoablation electrode rewarming reflects important determinants of cryoablation lesion formation--convective warming, contact pressure, and electrode orientation--that are not ascertainable during clinical ablation procedures.
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Affiliation(s)
- Babar Parvez
- Division of Cardiology and Department of Biostatistics, Virginia Commonwealth University Medical Center, Richmond, Virginia 23298-0053, USA
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Wood MA, Parvez B, Ellenbogen AL, Shaffer KM, Goldberg SM, Gaspar MP, Arief I, Schubert CM. Determinants of lesion sizes and tissue temperatures during catheter cryoablation. Pacing Clin Electrophysiol 2007; 30:644-54. [PMID: 17461875 DOI: 10.1111/j.1540-8159.2007.00726.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Factors which influence lesion size from catheter-based cryoablation have not been well described. This study describes factors which influence lesion size during catheter cryoablation. METHODS AND RESULTS Cryoablation was delivered to porcine left ventricular myocardium in a saline bath using 4- or 8-mm electrode catheters. Ablation was delivered with the electrodes either vertical or horizontal to the tissue and both with and without superfusate flow over the electrode. The effect of electrode contact pressure was tested. Lesion dimensions were measured. All experiments were duplicated to measure tissue temperatures at 1-, 2-, 3-, and 5-mm deep to the ablation electrode. The 8-mm electrode produced lower tissue temperatures and larger lesion volumes when compared with the 4-mm electrode (all P < 0.05). Superfusate flow slowed the rate of tissue cooling, markedly warmed tissue temperatures, and reduced lesion volume when compared with no flow conditions. By linear regression modeling, lesion sizes and tissue temperatures were related to the presence of superfusate flow, electrode orientation, contact pressure and electrode size, or catheter refrigerant flow rate (r2 for models = 0.90-0.96, all P < 0.001). Electrode temperature predicted lesion size or tissue temperatures only when analyzed independent of electrode size or refrigerant flow rate. CONCLUSIONS Lesion sizes and tissue temperatures during catheter cryoablation are related to convective warming, electrode orientation, electrode contact pressure, and any of the following: electrode size, catheter refrigerant flow rate or electrode temperature. However, electrode temperature may be a poor predictor of lesion size and tissue temperature for a given catheter size.
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Affiliation(s)
- Mark A Wood
- Department of Cardiology, Virginia Commonwealth University Medical Center, Richmond, Virginia 23298-0053, USA.
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Chumlea WC, Schubert CM, Sun SS, Demerath E, Towne B, Siervogel RM. A review of body water status and the effects of age and body fatness in children and adults. J Nutr Health Aging 2007; 11:111-8. [PMID: 17435953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
Abstract
BACKGROUND Most investigations of TBW, ECW and body composition and reports of their intra-body relationships were published prior to 1980. Distributional TBW and ECW relationships within the body have been considered fixed, but there was evidence these relationships were affected by the level of fatness. Body composition models based on past findings and assumptions could produce inaccurate estimates when the majority of the population is overweight to obese. METHODS TBW and ECW volumes, their proportions of body weight, FFM and percent body fat and associations with age are considered in U.S. children and adults. This review focuses on studies reporting measured body water volumes from large samples except for the national predicted values from NHANES III. RESULTS Measured TBW volumes for children and adults are almost exclusively from whites with the exception of the estimated values from NHANES III for non-Hispanic black and Mexican-Americans. Mean adult TBW volumes are as much as 9 liters greater than those reported prior to 1980. Low mean percentages of TBW%WT reflect the greater level of adiposity in children and adults, and this level of adiposity affects the value of TBW% FFM. Mean ECW volumes for white adults are 10 to 12 liters larger than those reported previously. With greater fatness in adults, ECW%TBW has increased to near 60%, and this implies that a calculation of FFM based on 73% and an ECW%TBW of 25-45% could produce an overestimation but more important clinically an underestimation of body fatness. CONCLUSION There is inadequate timely information on measured total and extra-cellular water volumes for the population. Available data indicate a coincident increase in body water with overweight and obesity, and a shifting in the proportion of ECW in TBW. Clinical and pharmacological treatments based upon past assumptions of body water volumes, proportions and relationships could produce inaccurate estimates.
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Affiliation(s)
- Wm C Chumlea
- Wright State University Boonshoft School of Medicine, Department of Community Health, Lifespan Health, Research Center, 3171 Research Blvd, Dayton, OH 45420, 937-775-1428, USA.
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Schubert CM, Rogers NL, Remsberg KE, Sun SS, Chumlea WC, Demerath EW, Czerwinski SA, Towne B, Siervogel RM. Lipids, lipoproteins, lifestyle, adiposity and fat-free mass during middle age: the Fels Longitudinal Study. Int J Obes (Lond) 2006; 30:251-60. [PMID: 16247511 DOI: 10.1038/sj.ijo.0803129] [Citation(s) in RCA: 95] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Although lipid profiles tend to worsen with age, it is not fully known if such age-related changes are influenced primarily by body composition and lifestyle or by other aspects of aging. OBJECTIVE We investigated the extent to which the fat and fat-free components of body mass index (BMI) and lifestyle factors influence patterns of change in lipids independent of age. DESIGN Serial data were analyzed using sex-specific longitudinal models. These models use serial data from individuals to assume a general pattern of change over time, while allowing baseline age and the rate of change to vary among individuals. SUBJECTS Serial data were obtained from 940 examinations of 269 healthy white participants (126 men, 143 women), aged 40-60 years, in the Fels Longitudinal Study. MEASUREMENTS Measurements included age, the fat (FMI) and fat-free mass (FFMI) components of BMI, high-density lipoprotein (HDL-C), low-density lipoprotein (LDL-C), triglycerides (TG), total cholesterol (TC), fasting glucose and insulin, physical activity, alcohol use and smoking, and women's menopausal status and estrogen use. RESULTS In both sexes, increased FMI was significantly associated with increased LDL-C, TG and TC, and decreased HDL-C. Increased FFMI was significantly related to decreased HDL-C and increased TG. Independent age effects remained significant only for LDL-C and TC in men and TC in women. Increased insulin was significantly related to increased TG in women. Moderate alcohol consumption was associated with higher HDL-C in men. Physical activity lowered male LDL-C and TC levels, and increased female HDL-C levels. Menopause was associated with increases in LDL-C. Premenopausal women not using estrogen had significantly lower HDL-C, TG, and TC than postmenopausal women taking estrogen. CONCLUSIONS (1) Age is an important independent predictor for LDL-C and TC in men, and TC in women, but it is not as influential as body composition and lifestyle on HDL-C and TG in men and women, and LDL-C in women. (2) Increasing FMI is the major contributor to elevated TC, LDL-C and TG levels, and decreased HDL-C levels in men and women. (3) FFMI significantly influences HDL and TG levels in both sexes. (4) Maintaining a lower BMI via a reduced fat component may be more beneficial in lowering CVD risks than other factors.
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Affiliation(s)
- C M Schubert
- Lifespan Health Research Center, Department of Community Health, Wright State University School of Medicine, Dayton, OH 45420, USA.
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Abstract
Background—
Gaps of sufficient cross-sectional dimensions within linear radiofrequency (RF) lesions may allow conduction through the lesion. The purpose of this study was to examine the effects of different gap geometries on conduction through discontinuous RF lesions.
Methods and Results—
Radiofrequency lesions were created in isolated, perfused rabbit right ventricular (RV) free wall preparations to produce gaps with 3 different lesion geometries: straight, bifurcated, and angled (n=10 each group). Angled preparations contained 2 right angles within the conduction path. Optical mapping was used to assess bidirectional conduction through the myocardium before and after gap formation during pacing at 1000-, 400-, and 200-ms cycle lengths. Histological analysis was performed on each preparation after optical mapping. After lesion formation, 9 of 10 straight gap preparations and 1 of 10 angled gap preparations demonstrated bidirectional conduction (
P
<0.001) at all cycle lengths. Nine of 10 bifurcated gap preparations demonstrated bidirectional conduction and 1 demonstrated unidirectional conduction at all cycle lengths. Two bifurcated gap preparations showed rate-dependent unidirectional 2:1 conduction. All unidirectional and rate-dependent block occurred during impulse propagation in the direction of diverging arms of the bifurcation. The occurrence of bidirectional conduction in the gaps was associated with the gap geometry (
P
<0.0001). Histological analysis confirmed the continuity of viable myocardium transmurally throughout the length of the gap in each preparation. The sites of conduction block were demonstrated to be just after the first angle in the conduction path for angled gaps and at the branch point of a bifurcated gap. The predominant myofiber orientation was changed relative to the conduction path at angulations of the gaps. Flecainide (0.1 μmol/L) produced bidirectional conduction block in straight and bifurcated gap preparations with bidirectional conduction at baseline.
Conclusions—
Conduction through discontinuities in RF lesions is associated with gap geometry. Complex gap geometry may allow for unidirectional and/or rate-dependent block. Gaps within RF lesions are susceptible to pharmacological blockade.
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Affiliation(s)
- Francisco J Pérez
- Department of Cardiology, Virginia Commonwealth University Medical Center, Richmond, VA 23298-0053, USA
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Demerath EW, Schubert CM, Maynard LM, Sun SS, Chumlea WC, Pickoff A, Czerwinski SA, Towne B, Siervogel RM. Do changes in body mass index percentile reflect changes in body composition in children? Data from the Fels Longitudinal Study. Pediatrics 2006; 117:e487-95. [PMID: 16510627 DOI: 10.1542/peds.2005-0572] [Citation(s) in RCA: 181] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Our aim was to examine the degree to which changes in BMI percentile reflect changes in body fat and lean body mass during childhood and how age and gender affect these relationships. METHODS This analysis used serial data on 494 white boys and girls who were aged 8 to 18 years and participating in the Fels Longitudinal Study (total 2319 observations). Total body fat (TBF), total body fat-free mass (FFM), and percentage of body fat (%BF) were determined by hydrodensitometry, and then BMI was partitioned into its fat and fat-free components: fat mass index (FMI) and FFM index (FFMI). We calculated predicted changes (Delta) in FMI, FFMI, and %BF for each 10-unit increase in BMI percentile using mixed-effects models. RESULTS FFMI had a linear relationship with BMI percentile, whereas FMI and %BF tended to increase dramatically only at higher BMI percentiles. Gender and age had significant effects on the relationship between BMI percentile and FFMI, FMI, and %BF. Predicted Delta%BF for boys 13 to 18 years of age was negative, suggesting loss of relative fatness for each 10-unit increase in BMI percentile. CONCLUSIONS In this longitudinal study of white children, FFMI consistently increased with BMI percentile, whereas FMI and %BF had more complicated relationships with BMI percentile depending on gender, age, and whether BMI percentile was high or low. Our results suggest that BMI percentile changes may not accurately reflect changes in adiposity in children over time, particularly among male adolescents and children of lower BMI.
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Affiliation(s)
- Ellen W Demerath
- Lifespan Health Research Center, Wright State University School of Medicine, Dayton, Ohio, USA.
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Chumlea WC, Schubert CM, Reo NV, Sun SS, Siervogel RM. Total body water volume for white children and adolescents and anthropometric prediction equations: the Fels Longitudinal Study. Kidney Int 2006; 68:2317-22. [PMID: 16221235 DOI: 10.1111/j.1523-1755.2005.00692.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND There are few studies of total body water (TBW) volume in children. Such studies are needed, as are new prediction equations for the clinical management of children with renal insufficiency and those receiving dialysis. METHODS Mixed longitudinal data were from 124 white boys and 116 white girls 8 to 20 years of age. TBW volume was measured by deuterium nuclear magnetic resonance spectroscopy, and random effects models were used to determine patterns of change over time. Sex-specific TBW prediction equations were developed using regression analysis. RESULTS Boys had significantly greater (P < 0.05) mean TBW volumes than girls at all but 3 ages. TBW was significantly (P < 0.05) associated with age and maturation in the boys and the girls. In boys, mean TBW/WT varied from 0.55 to 0.59, while in the girls the mean declined from 0.53 to 0.49 by 16 years of age. Boys had significantly larger means for TBW/WT than girls, who had a significant, slight negative trend with age. The prediction equations were TBW = -25.87 + 0.23 (stature) + 0.37 (weight) for boys and TBW =-14.77 + 0.18 (stature) + 0.25 (weight) for girls. CONCLUSION Means are provided for TBW in white children from 8 to 20 years of age, whose average fatness affected the percentage of TBW in body weight. These updated TBW prediction equations perform better than those available from the past.
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Affiliation(s)
- William C Chumlea
- Department of Community Health, Wright State University School of Medicine, Dayton, OH 45420, USA.
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Schubert CM, Chumlea WC, Kulin HE, Lee PA, Himes JH, Sun SS. Concordant and discordant sexual maturation among U.S. children in relation to body weight and BMI. J Adolesc Health 2005; 37:356-62. [PMID: 16227119 DOI: 10.1016/j.jadohealth.2005.03.009] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2004] [Revised: 02/25/2005] [Accepted: 03/01/2005] [Indexed: 11/22/2022]
Abstract
PURPOSE This study investigates the extent to which discordant Tanner stages for sexual maturity indicators are associated with weight and body mass index (BMI) and their variation during adolescence. Discordant children with large differences in weight and BMI may require additional monitoring of their growth during adolescence. METHODS Weight, BMI and Tanner stages, pubic hair in each gender, breast development in girls and genital development in boys, from 2103 boys and 2104 girls aged 8-18 years (average age 13.34 years) from the National Health and Nutrition Examination Survey III (NHANES III, 1988-1994) were analyzed. These cross-sectional data were grouped as concordant: assessed stages for paired indicators were equivalent, or as discordant: assessed stage for one paired indicator was greater or less than the other by one or more stages. Weight and BMI were compared separately by gender and race between concordant and discordant groups using analysis of covariance adjusted for age. RESULTS Approximately 65-69% of all children were concordant, genital stage equaled pubic hair stage for boys and breast stage equaled pubic hair stage for girls. For all three racial groups, boys whose genital stage was more advanced than their pubic hair stage had significantly smaller weight and BMI (p<.05) than either concordant boys or boys whose pubic hair stage was more advanced than their genital stage. For all three racial groups, girls whose breast stage was more advanced than their pubic hair stage had significantly greater weight and BMI than girls whose pubic hair stage was more advanced than breast stage. Non-Hispanic black and Mexican-American girls whose breast stage was more advanced than their pubic hair stage had significantly greater weight and BMI that the respective concordant girls. CONCLUSION Substantial and significant differences occur in weight and BMI among discordant and concordant children, and these differences are larger than between early and late maturing children.
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Affiliation(s)
- Christine M Schubert
- Department of Community Health, School of Medicine, Wright State University, Dayton, Ohio, USA.
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Sun SS, Schubert CM, Liang R, Roche AF, Kulin HE, Lee PA, Himes JH, Chumlea WC. Is sexual maturity occurring earlier among U.S. children? J Adolesc Health 2005; 37:345-55. [PMID: 16227118 DOI: 10.1016/j.jadohealth.2004.10.009] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2004] [Revised: 10/15/2004] [Accepted: 10/25/2004] [Indexed: 11/24/2022]
Abstract
PURPOSE To compare the onset and completion of sexual maturation among U.S. children between 1966 and 1994. METHODS Tanner stages were from 3042 non-Hispanic white boys, 478 black boys, 2625 white girls, and 505 black girls (NHES 1966-70), from 717 Mexican-American boys and 712 Mexican-American girls (HHANES 1982-84) and from 259 non-Hispanic white boys, 411 black boys, 291 white girls, 415 black girls, 576 Mexican-American boys and 512 Mexican-American girls (NHANES III 1988-1994). Proportions of entry into a stage, probit analysis estimated medians and selected percentiles for ages at entry were calculated using SUDAAN. RESULTS NHANES III (1988-1994) non-Hispanic white boys entered stage 2, 3, and 4 genital development and stages 3 and 4 pubic hair earlier than NHES (1966-1970) white boys, but they entered stage 5 genital development significantly later. NHANES III (1988-1994) Mexican-American boys were in stage 2, 3 and 4 genital development earlier than HHANES (1982-1984) boys, but entry into stage 5 genital and pubic hair development was not significant. NHANES III (1988-1994) white girls entered stage 5 pubic hair later than NHES (1966-1970) white girls. NHANES III (1988-1994) Mexican-American girls entered stage 2 breast and pubic hair development earlier than HHANES (1982-1984) girls, entered stage 4 breast and pubic hair development earlier but entered stage 5 pubic hair later than the HHANES (1982-1984) girls. CONCLUSION Persuasive evidence of a secular trend toward early maturation is not found between 1966 and 1994 in non-Hispanic black boys and non-Hispanic black and white girls. Some evidence of this trend is found in non-Hispanic white boys between 1966 and 1994 and in Mexican-American boys and girls between 1982 and 1994.
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Affiliation(s)
- Shumei S Sun
- The Lifespan Health Research Center, Department of Community Health, Wright State University, School of Medicine, Dayton, Ohio, USA.
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